[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
H.R. ____, ``RESTORING ACCOUNTABILITY IN THE INDIAN HEALTH
SERVICE ACT OF 2023''
=======================================================================
LEGISLATIVE HEARING
before the
SUBCOMMITTEE ON INDIAN AND INSULAR AFFAIRS
of the
COMMITTEE ON NATURAL RESOURCES
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
Thursday, July 27, 2023
__________
Serial No. 118-53
__________
Printed for the use of the Committee on Natural Resources
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
or
Committee address: http://naturalresources.house.gov
_________
U.S. GOVERNMENT PUBLISHING OFFICE
53-077 PDF WASHINGTON : 2023
COMMITTEE ON NATURAL RESOURCES
BRUCE WESTERMAN, AR, Chairman
DOUG LAMBORN, CO, Vice Chairman
RAUL M. GRIJALVA, AZ, Ranking Member
Doug Lamborn, CO
Robert J. Wittman, VA
Tom McClintock, CA
Paul Gosar, AZ
Garret Graves, LA
Aumua Amata C. Radewagen, AS
Doug LaMalfa, CA
Daniel Webster, FL
Jenniffer Gonzalez-Colon, PR
Russ Fulcher, ID
Pete Stauber, MN
John R. Curtis, UT
Tom Tiffany, WI
Jerry Carl, AL
Matt Rosendale, MT
Lauren Boebert, CO
Cliff Bentz, OR
Jen Kiggans, VA
Jim Moylan, GU
Wesley P. Hunt, TX
Mike Collins, GA
Anna Paulina Luna, FL
John Duarte, CA
Harriet M. Hageman, WY
Grace F. Napolitano, CA
Gregorio Kilili Camacho Sablan,
CNMI
Jared Huffman, CA
Ruben Gallego, AZ
Joe Neguse, CO
Mike Levin, CA
Katie Porter, CA
Teresa Leger Fernandez, NM
Melanie A. Stansbury, NM
Mary Sattler Peltola, AK
Alexandria Ocasio-Cortez, NY
Kevin Mullin, CA
Val T. Hoyle, OR
Sydney Kamlager-Dove, CA
Seth Magaziner, RI
Nydia M. Velazquez, NY
Ed Case, HI
Debbie Dingell, MI
Susie Lee, NV
Vivian Moeglein, Staff Director
Tom Connally, Chief Counsel
Lora Snyder, Democratic Staff Director
http://naturalresources.house.gov
------
SUBCOMMITTEE ON INDIAN AND INSULAR AFFAIRS
HARRIET M. HAGEMAN, WY, Chair
JENNIFFER GONZALEZ-COLON, PR, Vice Chair
TERESA LEGER FERNANDEZ, NM, Ranking Member
Aumua Amata C. Radewagen, AS Gregorio Kilili Camacho Sablan,
Doug LaMalfa, CA CNMI
Jenniffer Gonzalez-Colon, PR Ruben Gallego, AZ
Jerry Carl, AL Nydia M. Velazquez, NY
Jim Moylan, GU Ed Case, HI
Bruce Westerman, AR, ex officio Raul M. Grijalva, AZ, ex officio
CONTENTS
----------
Page
Hearing held on Thursday, July 27, 2023.......................... 1
Statement of Members:
Hageman, Hon. Harriet M., a Representative in Congress from
the State of Wyoming....................................... 1
Leger Fernandez, Hon. Teresa, a Representative in Congress
from the State of New Mexico............................... 3
Johnson, Hon. Dusty, a Representative in Congress from the
State of South Dakota...................................... 4
Statement of Witnesses:
Marchand, Cynthia, Secretary, Tribal Council, Confederated
Tribes of the Colville Reservation, Nespelem, Washington... 6
Prepared statement of.................................... 7
Questions submitted for the record....................... 10
Spoonhunter, Lee, Billings Area Representative, National
Indian Health Board, Washington, DC........................ 12
Prepared statement of.................................... 13
Questions submitted for the record....................... 21
Church, Jerilyn, Executive Director, Great Plains Tribal
Leaders Health Board, Rapid City, South Dakota............. 22
Prepared statement of.................................... 24
Questions submitted for the record....................... 25
Additional Materials Submitted for the Record:
Submissions for the Record by Representative Grijalva
United South and Eastern Tribes, Statement for the Record 32
LEGISLATIVE HEARING ON H.R. ____, TO AMEND THE INDIAN HEALTH CARE
IMPROVEMENT ACT TO IMPROVE THE RECRUITMENT AND RETENTION OF EMPLOYEES
IN THE INDIAN HEALTH SERVICE, RESTORE ACCOUNTABILITY IN THE INDIAN
HEALTH SERVICE, IMPROVE HEALTH SERVICES, AND FOR OTHER PURPOSES,
``RESTORING ACCOUNTABILITY IN THE INDIAN HEALTH SERVICE ACT OF 2023''
----------
Thursday, July 27, 2023
U.S. House of Representatives
Subcommittee on Indian and Insular Affairs
Committee on Natural Resources
Washington, DC
----------
The Subcommittee met, pursuant to notice, at 2:22 p.m., in
Room 1334, Longworth House Office Building, Hon. Harriet
Hageman [Chairwoman of the Subcommittee] presiding.
Present: Representatives Hageman, Carl; and Leger
Fernandez.
Also present: Representative Johnson.
Ms. Hageman. The Subcommittee on Indian and Insular Affairs
will come to order. Without objection, the Chair is authorized
to declare recess of the Subcommittee at any time. In fact,
that may be necessary as we have one more vote series today,
but we might be able to get through all the testimony, we will
just see how the schedule goes.
The Subcommittee is meeting today to hear testimony on a
Discussion Draft of the ``Restoring Accountability in the
Indian Health Service Act of 2023.'' Under Committee Rule 4(f),
any oral opening statements at hearings are limited to the
Chairman and the Ranking Minority Member. I therefore ask
unanimous consent that all other Member's opening statements be
made part of the hearing record if they are submitted in
accordance with Committee Rule 3(o).
Without objection, so ordered.
I ask unanimous consent that the gentleman from South
Dakota, Mr. Johnson, be allowed to sit and participate in
today's hearing.
Without objection, so ordered.
I will now recognize myself for an opening statement.
STATEMENT OF THE HON. HARRIET M. HAGEMAN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF WYOMING
Ms. Hageman. Today, the Subcommittee is meeting to consider
a discussion draft of the ``Restoring Accountability in the
Indian Health Service Act of 2023.'' This legislation aims to
provide tools so the agency can recruit and retain the very
best people. The bill would do this by aligning IHS's pay
system with the Veterans Administration's, providing better and
slightly expanded benefits for healthcare workers, direct
higher authority, improving data collection on patient care,
among other reforms.
The legislation would streamline processes to get rid of
unqualified and even predatory staff in an efficient way that
protects patients and improves care. The bill would also
confirm whistleblower protections that protect those who bring
issues to the attention of the IHS, the Department of Health
and Human Services, and Congress. The bill also includes
several required reports on the reforms that would be
instituted to make sure they work as Congress intended.
It is a goal of this hearing to discuss what provisions of
this draft bill are still needed and what changes and other
improvements to IHS can be included. The IHS has long been
plagued with issues of substandard medical care, high staff
vacancy rates, aging facilities and equipment, and unqualified
or predatory healthcare staff. Many of these issues first came
to national attention in 2010 when the Senate Committee on
Indian Affairs held a hearing and completed subsequent
investigation on the issues surrounding IHS of the Great Plains
area, showing in detail the extreme deficiencies across IHS
Direct Service Health Units.
The agency has self-identified that its inability to
attract and retain quality employees has a domino effect on the
quality of care they provide. It is disheartening and
frustrating to think about how long these issues have
continued. In 2015, further issues came to light in the Great
Plains area resulting in the termination of CMS contracts, the
closure of an emergency department, and the deaths of nine
patients. And in Fiscal Year 2021, the Portland area reported
100 percent of their dentist positions were vacant.
Vacancies are not the only issue. Issues of hiring sub-par
candidates, lengthy hiring timelines, and lower-tier benefits
have also factored into the issues of staffing IHS facilities.
One doctor was hired at an IHS facility in the Southwest
without consideration of all medical licenses, ignoring
disciplinary marks she had received in other states. Another
doctor who was unable to find work in other Southwest area
hospitals was hired at IHS after five malpractice settlements
in 5 years.
These are just two grievous examples that highlight the
policy changes that need to be made. While IHS does have
authority to improve some of these issues on its own, statutory
efforts is the most certain way to provide stronger guidelines
and require oversight. This draft legislation works toward this
goal and has the two-pronged approach of also including more
incentives for medical professionals to come work at IHS for
the betterment of the served communities. We must do better for
our American Indians and Alaska Natives. This conversation and
this discussion draft is a start.
We have now had several hearings dealing with the IHS and
our ability or inability to provide adequate medical and dental
services to our Native people in the United States. We have had
several women who have come to testify and provided extensive
information and detail about what they have encountered for
their tribal members, and it is just simply unacceptable. We
need to fix this, and I am hoping that this is an excellent
step in that direction. There are many aspects of the IHS and
Native healthcare that can be improved, and I hope this hearing
pushes those conversations forward.
I want to thank all of our witnesses for appearing before
the Subcommittee today, and I look forward to a robust
discussion on this important issue.
The Chair now recognizes the Ranking Minority Member for
any statement.
STATEMENT OF THE HON. TERESA LEGER FERNANDEZ, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW MEXICO
Ms. Leger Fernandez. Thank you, Madam Chairwoman, and thank
you, witnesses, for coming and sharing with us your expertise,
for sharing with us your written testimony.
The Indian Health Service and the work they do on behalf of
American Indians and Alaska Natives is critical. What they do,
and sometimes what they fail to do, is a matter of life and
death, and we need to remember that the life expectancy for
American Indians and Alaska Natives is just 65 years old. That
is 10 years lower than the national average. That is
unacceptable. Congress and IHS simply have to do better.
So, the draft discussion, which is great because we can
have a discussion about it, the ``Restoring Accountability in
the Indian Health Service Act'' is a good starting point. I do
appreciate the sponsors and this Committee's focus on the IHS
and the bill's intent to address many of the issues that the
IHS faces.
As an example, recruiting and retaining medical providers
remains a serious challenge for the IHS, given the rural
communities they serve. With that in mind, the draft bill would
provide tenant-based rental assistance to an employee of the
service who agrees to serve for not less than 1 year. It also
expands the IHS loan repayment eligibility to attract more
professionals. Things I hear about all the time, both of those,
housing and let's get some professionals from here and get them
back and recruit them.
The draft bill would also require HHS to update its 2006
Tribal Consultation Policy every 5 years and establish a
demonstration project where IHS may provide service units with
additional resources. They are meaningful provisions. They have
the potential to translate into better service and care
outcomes.
However, we know our witnesses here are going to tell us, I
have read it in your written testimony, that Congress has
grossly underfunded the Indian Health Service compared to its
current need. Historic underfunding contributes directly to
shortages and adequate healthcare for tribal patients,
resulting in gaps in treatment or referrals to outside
facilities, which could be impossible for some tribal members
who are living in rural communities.
In fact, the 2018 U.S. Broken Promises Report noted the
annual budget request for IHS meets just over half of the
needs. As one example of this underfunding, IHS hospitals are
overcrowded and falling apart. They have an average age of
around 40 years compared to about 10 in the private sector. I
have seen these hospitals; I have seen the leaky roofs. The
Gallup Indian Medical Center has been on the priority list for
way too long. It is clear that the Federal Government has not
delivered on its trust and treaty promises to Indian Country.
Despite the additional IHS programs and requirements in
this draft bill, it doesn't authorize any additional
appropriations to accomplish the goals it sets out. And I
appreciate the funding inquiries for IHS and the current House
Interior Environment Appropriations bill. But that is still
$2.2 billion less than what the Administration requested.
Our witness from the National Indian Health Board also
highlights in his testimony that funding for IHS this year
should be roughly $50 billion. In other words, the current
proposed funding is seven times less than what is needed. If
Congress continues to underfund the Service, we won't make the
progress we need to.
So, I thank you, Madam Chair, for hearing this bill. I hope
you will also be willing to work together so we can support
additional funding for IHS to address the concerns of this bill
and to meet the expectations. This draft, however, does help
IHS in offering critical, culturally-competent, culturally-
competent, that is so key, healthcare services through its
provisions to improve hiring and retention, to require cultural
training for certain employees, and encourage greater
transparency and dialogue between the tribes and the IHS.
Improving IHS care with appropriate funding, creative
authorities, and accountability is important work that our
Committee should and is addressing today.
I am committed to working with the tribes, the IHS, and the
Majority to do just that. As part of this work, it is key that
we hear directly from tribes across the country and with direct
service providers and 638 contracts and compacts. Indian
Country deserves better care. Let's get it to them.
With that, I yield back.
Ms. Hageman. Thank you. The Chair now recognizes Mr.
Johnson for 5 minutes to speak on his legislation.
STATEMENT OF THE HON. DUSTY JOHNSON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF SOUTH DAKOTA
Mr. Johnson. Thank you, Madam Chair and Madam Ranking
Member.
When I am traveling in Indian Country in South Dakota, of
course you hear a lot of concerns, lots of tribal members will
note areas for improvement. We will talk about transportation,
we will talk about law enforcement, we will talk about economic
development. But no topic comes up more often than IHS. And
these can, as our witnesses know, be very emotional
conversations because we are dealing with some of the most
important issues that people deal with in their lives, the
health of themselves and their family members.
And this is a progress that Members of Congress have cared
about this a long time. These concepts were originally
introduced by Senators Barrasso and Thune and then
Congresswoman Noem way back in the 115th Congress. But we
continue to talk to experts because we realize that the
healthcare that is being provided is not meeting our needs, the
needs of tribal members.
There are a lot of reasons for that, but I think we know
that we are involved in a staffing crisis in the IHS system.
Many of the providers are excellent providers. You can see and
feel their compassion. But we also know that there are some
providers that are not competent and that there are not enough
providers in general.
Now you don't need to take my word for it, Madam Chair. A
staffing analysis from a few years ago, I think 2018, said that
there was a 25 percent vacancy rate for providers within IHS.
And anecdotally, those people who work for IHS are telling me
that it has gotten considerably worse since 2018.
Now those deficiencies in staffing, they do manifest
themselves in poorer outcomes. The Ranking Member mentioned the
alarming life expectancy numbers in Indian Country, and we see
that in South Dakota. The life expectancy of a Native American
in South Dakota is almost 20 years lower than for a white
person in South Dakota. There are a lot of reasons for that,
but IHS staffing concerns are clearly an important part of
that.
And they also manifest themselves sometimes in really
terrible headlines. The Chairman mentioned some of them. In
2015, when the Pine Ridge Emergency Room closed, and it wasn't
because of a lack of activity, this was an emergency room that
was and is needed there in Indian Country. It took until 2019
before there was a final report about what caused that closure.
It was staffing problems, it was inconsistent leadership, and
it was a lack of vision from IHS. Again, not my words, those
are the findings of the report. And then we have also had truly
unfortunate headlines where bad people are allowed to be
providers in the system, and in some instances, have
systematically abused people that they are to be caring for.
So, this is just a discussion draft. We know that this is
not a perfect format. That is why I am so grateful for our
witnesses because they are going to help us make this better.
But I think what we have here is a great start, an
opportunity to address things like credentialing, like hiring
practices, like accountability, like how do we coordinate and
get better information from the state medical boards so that we
know that these providers have not gotten in trouble somewhere
else.
Madam Chair, thanks for this opportunity. I am just so
grateful for us to work together to improve healthcare in
Indian Country.
Ms. Hageman. Thank you. The gentleman yields back. I will
now introduce our witnesses for our panel. Ms. Cindy Marchand,
Secretary, Tribal Counsel, Confederated Tribes of the Colville
Reservation; Mr. Lee Spoonhunter, the Rocky Mountain Area
Representative of the National Indian Health Board, and I am
very pleased to say a member of the Northern Arapaho Tribe in
the State of Wyoming; Ms. Jerilyn Church, Executive Director,
Great Plains Tribal Leaders Health Board. Welcome. We are
excited to have you, and we appreciate your willingness to work
with us on this incredibly important legislation.
Let me remind the witnesses that under Committee Rules,
they must limit their oral statements to 5 minutes, but their
entire statement will appear in the record. To begin your
testimony, please press the talk button on the microphone. We
use timing lights. When you begin, the light will turn green.
When you have 1 minute left, the light will turn yellow. At the
end of the 5 minutes, the light will turn red and I will ask
you to please complete your statement. I will also allow all
witnesses on the panel to testify before we begin our Member
questioning.
The Chair now recognizes Ms. Cindy Marchand for 5 minutes.
STATEMENT OF CYNTHIA MARCHAND, SECRETARY, TRIBAL COUNCIL,
CONFEDERATED TRIBES OF THE COLVILLE RESERVATION, NESPELEM,
WASHINGTON
Ms. Marchand. Thank you, Madam Chairwoman. Good afternoon,
Chairwoman Hageman, Ranking Member Leger Fernandez, and members
of the Committee. My name is Cindy Marchand, and I am the
Secretary of the Colville Business Council, the governing body
of the Colville Tribes. Thank you for inviting me to testify on
the ``Restoring Accountability in the Indian Health Service
Act.''
The Colville Tribes is a direct service tribe which means
that healthcare and associated billing and administrative
support is provided by Federal IHS employees. We are in the
beginning stages of contracting all IHS functions under the
Indian Self Determination Act, but this process will take time.
In the meantime, we have to rely on IHS.
My tribe has endured multiple problems with the IHS's
delivery of healthcare to our citizens during the past few
years. We support the Restoring Accountability in the IHS Act
and believe that its reforms are long overdue. Like other rural
communities recruiting and retaining health providers on the
Colville Reservation is challenging. There is a 55 percent
vacancy rate at the Colville Service Unit, which is nearly
twice the IHS-wide vacancy rate of 28 percent. We currently
have 46 vacancies out of a total of staff of 84, and many of
the vacant positions have been unfilled for years.
IHS's hiring and credentialing processes are extremely
slow. When a doctor or other healthcare provider applies for a
vacant position at the Colville Service Unit, they will often
accept a position elsewhere because they simply cannot wait for
IHS to complete its background and credential review processes,
which usually take months.
The recruitment and retention provisions in Title I of the
Act would help address some of these issues. Section 101 would
provide parity in the pay schedules for health providers at IHS
with those at the Veterans Health Administration and would also
expedite credentialing. The Colville Tribe supports these
reforms.
As the Committee is aware, Purchased/Referred Care, or PRC,
is a program where IHS beneficiaries receive care from private
non-IHS health providers when IHS is unable to provide the care
in its own facilities. For the 3-year period the IHS Portland
area office administered the PRC program at the Colville
Service Unit, during this time the PRC program was administered
so poorly that we can trace it to deaths in our community.
IHS required on an annual basis our members to produce
utility bills, certificates of Indian blood, and other proof of
tribal enrollment, and other information not required by the
IHS regulations or the IHS handbook to get PRC referrals. Those
who were unable to produce this information either went without
care or obtained care on their own and subsequently faced
third-party collection agencies when IHS refused to pay for the
services. To our knowledge, none of the IHS staff at the
Portland area office who imposed these obstacles to eligibility
have ever been held accountable.
Two years ago, one of our tribal elders tried repeatedly to
obtain a referral for ongoing heart issues and was unable to
get calls from IHS returned or otherwise secure a purchase
order for the referral by the IHS staff responsible for
processing them. The tribal elder died of a heart attack before
securing that referral.
There have been many stories like this in our tribal
communities, and me and my colleagues on the Colville Business
Council field these calls from our constituents regularly. If a
referral for PRC is secured, there is no way to predict if IHS
will pay the provider in a timely manner, if at all. When IHS
does not pay PRC providers, the providers send medical bills to
IHS beneficiaries directly.
Section 222 of the Indian Health Care Improvement Act
explicitly states that an IHS beneficiary should under no
circumstances be liable for payment for authorized PRC
services. IHS has never effectively implemented this provision,
and providers send the bills IHS does not pay to IHS
beneficiaries anyway. We have provided the Committee with
language to strengthen Section 222 and address these issues
that we would like to see included in Title I of the Act.
In conclusion, the Colville Tribe supports the bill and
would like to work with the Committee to ensure that the final
bill includes provisions to improve the PRC program for the
Colville Tribes and other direct service tribes. I would be
happy to answer any questions that the Committee may have.
Thank you.
[The prepared statement of Ms. Marchand follows:]
Prepared Statement of the Honorable Cindy Marchand, Secretary,
Confederated Tribes of the Colville Reservation
As a rural, land-based Indian tribe, the Confederated Tribes of the
Colville Reservation (``Colville Tribes'' or the ``CCT'') has unique
challenges to providing health care for our tribal community. The CCT
is a direct service tribe, which means that health care and associated
billing and administrative support is provided by Indian Health Service
(``IHS'') employees. The CCT is in the beginning stages of contracting
all IHS functions, but this process will take time. In the meantime, we
have to rely on IHS to provide quality health care to our tribal
citizens.
The Confederated Tribes of the Colville Reservation is a
confederation of twelve aboriginal tribes from across eastern
Washington state, northeastern Oregon, Idaho, and British Columbia. The
twelve constituent tribes historically occupied a geographic area
ranging from the Wallowa Valley in northeast Oregon, west to the crest
of the Cascade Mountains in central Washington State, and north to the
headwaters of the Okanogan and Columbia Rivers in south-central and
southeast British Columbia. Before contact, the traditional territories
of the constituent tribes covered approximately 39 million acres.
The present-day Colville Reservation is in north-central Washington
state and was established by Executive Order in 1872. The Colville
Reservation covers more than 1.4 million acres, and its boundaries
include portions of both Okanogan and Ferry counties, two of the lowest
median income counties in the state. Geographically, the Colville
Reservation is larger than the state of Delaware and is the largest
Indian reservation in the pacific Northwest. The Colville Tribes has
just under 9,300 enrolled members, about half of whom live on the
Colville Reservation.
The CCT appreciates the Committee holding today's hearing on the
``Restoring Accountability in the Indian Health Service Act of 2023''
(the ``Act''). The CCT worked extensively with the committees of
jurisdiction when the bill was first being developed in 2015. Much of
the bill focuses on IHS issues that are most relevant to direct service
tribes. As a direct service tribe that has endured multiple problems
with the IHS's delivery of health care to our citizens during the past
few years, the Colville Tribes supports the Act and believes that its
reforms are long overdue.
A. Recruitment and Retention
Like other rural communities, recruiting and retaining health
providers on the Colville Reservation is challenging. There is a 55
percent vacancy rate at the Colville IHS Service Unit, which is nearly
twice the IHS-wide vacancy rate of 28 percent that IHS Director Roslyn
Tso reported during her May 11, 2023, testimony before this Committee.
Currently, there is a single, part-time dentist at the Colville Service
Unit and many of the vacant positions have been unfilled for years.
Health providers in our area have expressed interest in providing
health care services on the Colville Reservation but have indicated
they would only do so if they contracted directly with the Colville
Tribes and bypass having to work through IHS. Providers have indicated
to us that the protracted administrative processes and problems locally
with IHS's administration of the Purchased/Referred Care (``PRC'')
program are the primary reasons for their interest working with the CCT
directly. When a doctor or other health provider applies for a vacant
position at the Colville Service Unit, they will often accept a
position elsewhere because they simply cannot wait for IHS to complete
its background and credential review processes, which often takes
months.
Every health provider vacancy at an IHS service unit creates a
domino effect that negatively impacts tribes and tribal citizens.
First, a provider vacancy means longer waits by IHS beneficiaries for
health care. Other providers must also absorb the patient load, which
often leads to providers burning out and looking for employment
elsewhere.
Worse, without enough providers, the user population for a given
IHS Service Unit has decreased, which ultimately reduces the Service
Unit's allocation of PRC funds under the PRC distribution formula.
IHS's Portland Area (which includes tribes in Washington, Oregon, and
Idaho) does not have and has never had an IHS or tribally operated
hospital. Without hospitals that can internalize costs, tribes in the
Portland Area are particularly reliant on PRC funds to refer patients
to private providers for specialty care that their facilities cannot
accommodate. For a direct service tribe, a single health provider
vacancy leads to multiple negative outcomes. The Colville Service Unit
currently has 46 vacancies out of a total staff of 84.
The recruitment and retention provisions in Title I of the Act
would help address some of these issues. Section 101 would provide
parity in the pay schedules for health providers at IHS with those at
the Veteran's Health Administration and would also authorize housing
assistance. The CCT supports these provisions and recommends that
Section 101 also add a provision that allows for incentives for service
unit CEOs or other senior management positions at the service unit
level. IHS recently advertised the CEO position at the Colville Service
Unit and, in the Tribes' view, the pay grade was initially too low to
attract the type of applicant to a rural area with the experience and
qualifications necessary to implement reforms in our Service Unit.
B. Staffing Demonstration Program
The CCT is particularly supportive of Section 108 of the Act, the
``Staffing Demonstration Program.'' The CCT developed this provision in
response to its challenges to update its staffing ratios, which have
not changed for nearly one hundred years.
The Colville Tribes has previously testified before this Committee
regarding the unique challenges that direct service tribes face in
updating their staffing levels. For the CCT and similarly situated
direct service tribes, these staffing ratios are determined when their
initial IHS health facility opens for operation. There are two ways for
direct service tribes to update their staffing levels. One is to
construct a new facility with IHS funds under the Facility Construction
Priority List (``Priority List''), and the other is to build a facility
using tribal funds under the Joint Venture program. The Priority List
has been closed since 1992 and remaining projects will cost an
estimated $6 billion to complete. Applications for Joint Venture
projects are rarely offered, highly competitive, and at the expense of
the tribes.
Tribes that have not been able to update their staffing ratios by
constructing a new facility under the Priority List or the Joint
Venture facility construction programs are frozen in time for staffing
ratio purposes. For the CCT, these historic staffing ratios date back
to 1927 when the U.S. Public Health Service converted a Department of
War building in Nespelem, Washington, for use as the CCT's initial
health clinic.
The Colville Tribes was fortunate to have been awarded a Joint
Venture facility construction project in 2020 and hopes to update its
staffing levels soon. Many other direct service tribes, however,
continue to face challenges associated with historically low staffing
levels. The Staffing Demonstration Program would allow the IHS to
provide federally managed service units with staffing resources on a
temporary basis with the expectation that third party revenue generated
by the staff would allow them to be permanent. There is currently no
other IHS program that allows this.
C. The Act Should Address IHS's Administration of the PRC Program
As noted above, the PRC program is critical for the Colville Tribes
and other Indian tribes in the Portland Area because of the lack of
inpatient hospital facilities. Based on the Colville Tribes'
experiences in recent years, more congressional oversight of IHS's
administration of the PRC program is not only warranted, but necessary,
as the PRC program for direct service tribes is literally a matter of
life and death.
For an approximately three-year period that ended in October 2022,
the Portland Area IHS Office administered the PRC program for the
Colville Service Unit in Portland using Portland Area Office staff, not
local IHS employees located on-reservation. This led to catastrophic
results, including deaths. The severity of these issues prompted the
House Committee on Appropriations to direct IHS to brief the Committee
on its efforts to improve care at the Colville Service Unit in its
report accompanying the FY 2024 Interior spending bill, which the
Committee approved last week.
Once the Portland Area Office began administering the PRC program,
IHS began imposing onerous documentation requirements not required by
the IHS handbook or any other IHS authority on Colville tribal members
to prove they were eligible for PRC funds. This meant that tribal
elders and other IHS beneficiaries, on an annual basis, had to produce
utility bills, certificates of Indian blood and other proof of tribal
enrollment, and other information not required by the IHS regulations
or the IHS handbook in order to get referrals for specialty care. Those
who were unable to produce this information either went without care or
obtained care on their own and subsequently faced third party
collection agencies when IHS refused to pay for the services.
The Portland IHS Area Director informed the CCT in late 2022 that
the additional eligibility requirements should never have been
implemented. The damage had already been done, however, and there has
never been accountability for those Portland Area IHS personnel that
ordered the eligibility requirements implemented at the Colville
Service Unit.
In addition to eligibility roadblocks, the communication and
beneficiary customer service that IHS provides at the Colville Service
Unit has been woeful. Two years ago, a Colville tribal elder tried
repeatedly to obtain a referral for ongoing heart issues, complaining
to CCT elected officials that he was unable to get calls from IHS
returned or otherwise secure a purchase order for the referral by IHS
staff responsible for processing them. The tribal elder died of a heart
attack before securing the referral. Tragically, there have been many
stories like this in the Colville Tribes' tribal community.
For those CCT members who can get referrals and receive specialty
care through the PRC program, there is no way to predict if IHS will
pay the provider. When IHS does not pay PRC providers in a timely
manner, the providers will begin sending the medical bills to IHS
beneficiaries directly.
Section 222 of the Indian Health Care Improvement Act (IHCIA)
explicitly states that an IHS beneficiary should under no circumstances
be liable for payment for authorized PRC services. IHS has never
effectively implemented this provision, however, and providers send the
bills that IHS does not pay to IHS beneficiaries anyway, which are
often later referred to third party collection agencies. This has
happened to scores of Colville tribal members in recent years,
including CCT elected officials. The CCT is aware of instances where
PRC providers have refused to make appointments with IHS
beneficiaries--even those with chronic conditions--where the
beneficiary has an outstanding balance to the provider that IHS has not
paid and the provider has billed to the beneficiary directly.
When faced with notices from collection agencies, the few fortunate
IHS beneficiaries who can afford to, will pay the bills out-of-pocket
to avoid damage to their credit scores--again, notwithstanding Section
222 of the IHCIA. The IHS has no beneficiary-accessible mechanism for
reimbursing IHS beneficiaries in these situations. For the vast
majority of IHS beneficiaries that cannot afford to pay the bills that
IHS does not pay themselves, they must live with impaired credit
scores, higher interest rates, or the inability to obtain credit
altogether.
As the Committee and some in Indian Country are aware, in recent
years IHS has amassed hundreds of millions in unobligated PRC carryover
funds and billions more in carryover funds from other IHS accounts.
Despite this carryover, IHS administers the PRC program like rationed
healthcare. The fact that IHS has significant PRC carryover funds and
Colville tribal members and others in Indian Country struggle to obtain
referrals for PRC care is unconscionable. Even worse, when PRC
providers do not get paid by IHS in a timely manner, the CCT has seen
providers to refuse to participate in the PRC program. The Colville
Reservation is in a rural, low-income area where there are only a small
number of providers to begin with, so the loss of a provider
participating in the PRC program because of non-payment by IHS is
devastating.
The Colville Tribes has provided the Committee with language that
would amend section 222 of the IHCIA to clarify IHS's duties to inform
providers that the IHS beneficiaries are not liable for PRC bills and
require IHS to implement a reimbursement process for those IHS
beneficiaries who pay PRC bills that IHS does not pay. We urge the
Committee to consider including this language in Title I of the Act.
______
Questions Submitted for the Record to the Hon. Cindy Marchand,
Secretary, Tribal Council, Confederated Tribes of the Colville
Reservation
Ms. Marchand did not submit responses to the Committee by the
appropriate deadline for inclusion in the printed record.
Questions Submitted by Representative Westerman
Question 1. Previous versions of the Restoring Accountability in
the Indian Health Service Act included a section on medical chaperones.
Do you believe there still a need for medical chaperones for
patients at IHS facilities? If so, please elaborate on what language
should be added to this discussion draft to address the issue.
Question 2. Recruitment and retention of health care personnel are
two issues this committee has heard about time and time again,
especially in rural areas. The entire health care system faces
challenges of hiring and retaining medical professionals.
2a) Anecdotally, what barriers do you know medical professionals
face to work at either IHS or tribally run health care programs?
2b) What have you seen in tribally run health care programs
regarding improvements to hiring and recruitment that could help IHS
fill their staff vacancies and improve employee retention?
2c) What sections of this discussion draft could help with
recruitment and retention of personnel the most?
Question 3. There have been reports regarding the lack of
accountability when it comes to IHS employees and misconduct.
3a) Anecdotally, can you provide any examples of complaints toward
IHS medical staff not being taken seriously by IHS officials?
3b) Are you aware of any incidents that have not been previously
reported where an IHS employee retained their position despite
complaints being raised against them?
3c) Are the protections provided in this discussion draft enough
for IHS employees to raise objections and be certain they are safe to
do so?
Question 4. The NIHB raised the question of reimplementing a tribal
advisory committee like the National Steering Committee to Reauthorize
of the Indian Health Care Improvement Act (IHCIA) that had previously
advised the federal government about changes to the IHCIA, prior to its
permanent reauthorization.
4a) Would your tribe be supportive of that sort of committee being
established? What if the tribal leaders who serve on the committee
would serve without pay?
4b) What other advisory committees or councils that are currently
established in HHS or IHS that could be used to provide the expertise
the National Steering Committee previously provided?
4c) What further ways aside from a national steering committee may
be beneficial to institute so IHS will have more input from tribes on
how to improve IHS policies and procedures?
Question 5. Concerns were raised in NIHB written testimony about
the discussion draft affecting tribally run health programs that have
been compacted or contracted out from IHS.
5a) What sections of this discussion draft could most affect
tribally operated health programs and how?
5b) What language do you think should be included to reduce that
effect?
5c) Are there aspects of this discussion draft that would improve
tribal autonomy and control over tribally run health programs?
Question 6. From your perspective, what regulations and official
guidance from IHS cause the largest challenges for tribal members
seeking care? What about for tribes compacting or contracting out
health care services from IHS?
Question 7. In your testimony you explained that Confederated
Tribes of the Colville Reservation were in the process of contracting
out all IHS related functions. Could you provide more background as to
why that decision was made?
Question 8. In your testimony, you stated that provisions should be
included to Section 101 to allow for incentives to be given to Service
Unit CEOs as well as other upper management positions.
Could you elaborate on that idea and detail what kind of incentives
you think should be made available?
Question 9. Your testimony discussed the ``purchase/referred care''
(PRC) program and how tribes use the program. its use for tribal
entities, such as Colville. One of the core functions of the PRC
programs is its availability to provide care when staffing at
facilities fail to meet the needs of the patient base.
9a) Could you elaborate further on the various obstacles a tribe
faces when utilizing the program?
9b) Are there specific implementation issues related to IHS
staffing that could be addressed by the proposed changes in this
legislation?
Question 10. In your testimony you outlined IHS has had significant
carryover funds in the PRC program.
What would you recommend that IHS do with the PRC carryover that is
has for the Colville Service Unit or the Portland Area?
Question 11. In your written testimony you stated frustrations with
the staffing ratios at IHS, noting the limited ways that IHS will
change the ratios--either through constructing a new facility under
IHS' ``priority list,'' or building a facility using Joint Venture
funds.
11a) In your opinion, would the proposed ``staffing demonstration
program'' found in Section 108 of the discussion draft address this
issue?
11b) How else could the ratio be addressed by Congress to improve
review of the ratios for all IHS areas?
Questions Submitted by Representative Leger Fernandez
Question 1. A common theme throughout the hearing was the need for
Congress to hear directly from tribes and tribal organizations across
the country on any policies designed to improve direct or indirect IHS
care for American Indians and Alaska Natives.
1a) How do you believe Congress should consult with Tribes on their
unique experiences and perspectives to inform potential legislation to
improve the Indian Healthcare Improvement Act (IHCIA)?
1b) One recommendation put forward was for Congress to support a
National Steering Committee (NSC) process to examine necessary reforms
to IHS and IHCIA. How do you believe Congress can best support Tribes
in such processes to ensure policy outcomes are led by tribal leaders?
______
Ms. Hageman. I thank the witness for her testimony.
The Chair now recognizes Mr. Lee Spoonhunter for 5 minutes.
STATEMENT OF LEE SPOONHUNTER, BILLINGS AREA REPRESENTATIVE,
NATIONAL INDIAN HEALTH BOARD, WASHINGTON, DC
Mr. Spoonhunter. Chairwoman Hageman, Ranking Member Leger
Fernandez, and distinguished members of the Subcommittee, thank
you for this opportunity to provide testimony on the
``Restoring Accountability in the Indian Health Service Act.''
My name is Lee Spoonhunter. I serve as a tribal council member
for the Northern Arapaho Tribe and the Rocky Mountain Area
representative for the National Indian Health Board.
This bill arises from our conflicted past with the United
States and the staffing and accountability issues caused by
chronic underfunding of the Indian Health Service, and how
staffing shortages persist throughout Indian Country from top
to bottom. Earlier this year, I had just testified that it has
a 28 percent provider vacancy rate and a 40 percent mental
health professional vacancy rate. The lack of providers forces
IHS and tribal facilities to rely on contracted services, which
can be more costly, less effective, and culturally inept.
We are supportive of the intent of this bill to address
policy concerns at the IHS. However, we believe there is more
work needed before there are any amendments to the Indian
Healthcare Improvement Act. To that end, the bill should not
supersede any consensus recommendations of the IHCIA National
Steering Committee and should seek to empower collaborative
policy development around IHS accountability on a government-
to-government basis.
The draft bill has many well-intended provisions that seek
to address past misconduct and a lack of accountability at the
IHS, such as modifications to the IHS loan repayment plan,
streamlined hiring practices, and culturally-appropriate,
historically-accurate training for staff. The bill would also
address best practices for IHS area offices and service unit
governing boards as well as establish clear rules for
misconduct and disciplinary action. Unfortunately, we are
worried that the good intentions could negatively impact our
sovereignty. It could set us on a path backward in U.S. tribal
relations.
A number of issues addressed in this bill came up in the
regional and national meetings on the reauthorization of the
Indian Healthcare Improvement Act. For years, when it came to
renewing or modifying IHCIA, there was a national steering
committee charged with identifying the needed objectives and
policy changes for the law. The national steering committee
worked diligently to reach consensus on many issues, some of
which were contentious and controversial.
We call upon Congress to support a national focused
steering committee process again. We hear from tribal leaders
that there is a lack of transparency around activities and
decision-making at IHS, such as when a tribe receives its
services directly through the IHS operator service unit. We are
concerned that one of the issues with IHS accountability is
that there is not a clear and common understanding of what
gives them to rise in the first place.
When policy is enacted, the impact is often pushed on
direct service tribes with no explanation. We are concerned
that this bill has been developed so far without national
tribal consensus and could harm tribes and their past work.
However, we will not study this problem away. There is no
amount of red tape that can patch an underfunded system.
Imagine having one day's worth of food for a week for
generations.
The funding at IHS on one-seventh of the estimate of the
tribal budget formulation work groups sets us up for failure.
For example, at the Northern Arapaho, our tribal citizens are
at a disadvantage for referred care. Those dollars are so
limited that patients are not given the needed referrals until
they are often too sick to receive curative treatment. We
recently hired a nephrologist with our third-party revenue
dollars, someone that would not likely have been hired if we
had IHS direct care, who informed us that we could have greatly
improved patient care and saved lives if the care was provided
sooner. But the PRC dollars are so scarce it is often too late
by the time they get the referral.
Thank you again for this hearing and the draft legislation
addressing IHS staffing and accountability issues. I know that
if we work together as sovereigns we can do so much more. I
look forward to any questions you have. Thank you.
[The prepared statement of Mr. Spoonhunter follows:]
Prepared Statement of Councilman Lee Spoonhunter, Rocky Mountain Area
Representative, National Indian Health Board
Chairwoman Hageman, Ranking Member Leger Fernandez, and
distinguished members of the Subcommittee, on behalf of the National
Indian Health Board and the 574 sovereign federally recognized American
Indian and Alaska Native Tribal nations we serve, thank you for this
opportunity to provide testimony on the Restoring Accountability in the
Indian Health Service Act of 2023. My name is Lee Spoonhunter. I serve
as Tribal Councilmember for the Northern Arapaho Tribe and Rocky
Mountain Area Representative for the National Indian Health Board
(NIHB).
Formed in 1972, NIHB is recognized nationally and internationally
for its expertise in Indian health policy. NIHB's membership consists
of the eleven Area Indian Health Boards (AIHBs) and the Tribes of the
Tucson Area directly. NIHB supports Tribal policy through collaborative
partnerships with Tribal, Congressional, federal, state, and
International governmental and non-governmental organizations, as well
as through original research and development, public education, and
outreach.
The Indian Health Service (IHS) is the principal federal health
care provider and health advocate for Indian people. Its success is
essential to our success as an organization, and to meeting this
Nation's stated policy goal of ensuring the highest possible health
status for Indians. The NIHB, therefore, appreciates this
Subcommittee's focus on Indian healthcare and stands ready to work with
the Subcommittee toward achieving this national goal. We have a long
way to go.
The NIHB Board of Directors sets forth an annual Legislative and
Policy Agenda to advance the organization's mission and vision. Our
objectives are to educate policymakers about Tribal priorities,
advocate for and secure resources, build Tribal health and public
health capacity, and support Tribally led efforts to strengthen Tribal
health and public health systems. Today's testimony includes a subset
of recommendations from this Agenda.
IHS Accountability
``For decades and generations, IHS has had a notorious
reputation in Indian Country but it is all we have to count on.
We do not go there because they have superior health care; we
go there because it is our treaty right, and we go there
because many of us lack the resources to go elsewhere.''
2016 Statement of Victoria Kitcheyan, Treasurer, Winnebago
Tribal Council, to the Senate Committee on Indian Affairs.
The Restoring Accountability in the Indian Health Service Act of
2023 arises from our conflicted past relations with the United States
and from the chronic underfunding of the United States treaty and trust
obligations to provide for the health of Tribal nations and their
citizens.\1\ The NIHB is supportive of the intent of this draft
legislation to address policy concerns at the IHS. However, we believe
there is more work to be done to improve this legislation before there
are any amendments to the Indian Health Care Improvement Act (IHCIA).
To that end, the bill should not supersede any consensus
recommendations of the IHCIA National Steering Committee (NSC) and
should seek to empower collaborative policy development on a
government-to-government basis.
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\1\ See, U.S. Commission on Civil Rights, Broken Promises:
Continuing Federal Funding Shortfall for Native Americans (hereinafter
``Broken Promises''), available at: https://www.usccr.gov/files/pubs/
2018/12-20-Broken-Promises.pdf, accessed on: November 20, 2022.
---------------------------------------------------------------------------
Chronic and pervasive health staffing shortages--from physicians to
nurses to behavioral health practitioners--stubbornly persist across
Indian Country, with 1,550 healthcare professional vacancies documented
as of 2016. Further, a 2018 Government Accountability Office (GAO)
report found an average of 25% provider vacancy rates for physicians,
nurse practitioners, dentists, and pharmacists across two thirds of IHS
Areas (GAO 18-580). In May of this year, IHS Director Roselyn Tso
testified before this Subcommittee that the agency currently has a 28%
provider vacancy rate and a 40% mental health professional vacancy
rate. This challenge is not getting better. Lack of providers also
force IHS and Tribal facilities to rely on contracted providers, which
can be more costly, less effective, and culturally indifferent, at
best--inept at worst. Relying on contracted care reduces continuity of
care because many contracted providers have limited tenure, are not
invested in community and are unlikely to be available for subsequent
patient visits. Along with a lack of competitive salary options, many
IHS facilities are in a serious state of disrepair, which can be a
major disincentive to potential new hires. While the average age of
hospital facilities nationwide is about 10 years, the average age of
IHS hospitals is nearly four times that--at 37 years. In fact, an IHS
facility built today could not be replaced for nearly 400 years under
current funding practices. As the IHS eligible user population grows,
these aging facilities impose an even greater strain on availability of
direct care.
NIHB is glad to see that the draft legislation would focus on
improving staffing at the IHS. We must continue to think creatively
about how to recruit and retain the best medical professionals to the
Indian health system. We hope that we can continue this conversation
about how to attract the best providers to the agency. We are also glad
to see language to help improve and standardize the IHS. However, the
policies identified in this bill must be done with the necessary
appropriations to back them up. NIHB also supports ensuring that the
legislation would not impact Tribal health programs negatively, and
that the true needs of IHS are adequately reflected.
IHCIA and the National Steering Committee
A number of the issues addressed in the Restoring Accountability in
the Indian Health Service Act of 2023 came up in the regional and
national meetings on the reauthorization of the IHCIA. For years, when
it came to renewing and modifying IHCIA, there was a National Steering
Committee (NSC) that consisted of Tribal representatives from across
the country. During this process there were multiple regional
consultation meetings and a national consultation in Washington, DC.
This process identified the needed objectives and policy changes for
IHCIA. This allowed any amendments to IHCIA to be supported by Tribes
and for Indian Country to speak with a unified voice. The NSC worked
diligently to reach national consensus on many issues, some of which
were contentious or controversial.
As we work with the Subcommittee to support and examine necessary
reforms to IHS, we call upon Congress to support a nationally-focused
NSC process again. This process would balance the perspectives and
needs of the entire Tribal health system resulting in a consensus among
Indian Country and stakeholders. The NIHB stands with its partners and
allies that any federal policymaking should be respectful of the Tribal
leaders' decisions and policy outcomes that came through such process.
For example, NIHB consistently hears that there is that the lack of
transparency around activities and decision making at IHS, particularly
when a Tribe receives its services directly through an IHS operated
service unit. NIHB partners are concerned that one of the issues with
IHS accountability is that there is not a clear and common
understanding of the rules and procedures that give rise to these
issues. When policy is enacted regarding IHS, the impact of that policy
is often thrust upon Tribes receiving direct services from IHS to bear
regardless of whether the driving force of the underlying policy or
decision is explained. The IHS Restoring Accountability Act, to our
knowledge, was not a product of an NSC process. A considerable amount
of the policy in this bill has been developed and proposed without
national Tribal consensus and is at risk of inadvertently harming
Tribal nations and Tribal health systems.
Treaties, Trust, and the Duty Owed
Tribal nations have a unique legal and political relationship with
the United States as defined by the U.S. Constitution, treaties,
statutes, court decisions, and administrative law. Through its
acquisition of land and resources, the United States formed a fiduciary
relationship with Tribal nations whereby it has recognized a trust
relationship to safeguard Tribal rights, lands, and resources.\2\ In
fulfillment of this Tribal trust relationship, the United States
``charged itself with moral obligations of the highest responsibility
and trust'' toward Tribal nations.\3\ This bargained for exchange means
that Tribal nations paid, in full, for the duties owed by the United
States and that the United States has to duty to uphold its end of the
exchange, which it continues to generously benefit directly from.
---------------------------------------------------------------------------
\2\ Worcester v. Georgia, 31 U.S. 515 (1832).
\3\ Seminole Nation v. United States, 316 U.S. 286, 296-97 (1942).
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The United States' long-standing and repetitive use of language
regarding trust relationships and legal obligations is not by accident.
In a trust relationship, a trustee owes certain fundamental duties to
the beneficiaries, including a duty of loyalty to all beneficiaries, a
duty to provide requisite resources, and a duty to act in good faith.
The duty to provide requisite resources is not only one of quantity,
but one of continuity and stability. Otherwise, the purpose of the
trust relationship recognized by the United States for centuries is
effectively meaningless.
Most recently, Congress reaffirmed its duty to provide for Indian
health care when it enacted the Indian Health Care Improvement Act
(IHCIA) (25 U.S.C. Sec. 1602), declaring that it is the policy of this
Nation, in fulfillment of its special trust responsibilities and legal
obligations to Indians--to ensure the highest possible health status
for Indians and urban Indians and to provide all resources necessary to
effect that policy.'' Unfortunately, those responsibilities and legal
obligations remain unfulfilled and Indian Country remains in a health
crisis.
Today, most Tribal lands are held in trust by the United States or
have been completely taken from our Nations through the long history of
U.S. war, removal, assimilation, reorganization, and termination. As a
result, Tribes do not have the same asset base or tax base as other
governments. Tribal nations rely on federal government funding and on
economic development, but infringement on Tribal tax jurisdiction and
drastically reduced land bases leave most Tribal nations in a position
of unique reliance on annual appropriations for their healthcare
infrastructure and delivery.
The Health Status of Indian Country
The Centers for Disease Control and Prevention (CDC) now reports
that life expectancy for AI/ANs has declined by nearly 7 years, and
that our average life expectancy is now only 65 years--equivalent to
the nationwide average in 1944.\4\ With a life expectancy 10.9 years
less than the national average,\5\ Native Americans die at higher rates
that those of other Americans from chronic liver disease and cirrhosis,
diabetes mellitus, unintentional injuries, assault/homicide,
intentional self-harm/suicide, and chronic lower respiratory
disease.\6\ Native American women are 4.5 times more likely than non-
Hispanic white women to die during pregnancy.\7\ Between 2005 and 2014,
every racial group experienced a decline in infant mortality except for
Native Americans \8\ who had infant mortality rates 1.6 times higher
than non-Hispanic whites and 1.3 times the national average.\9\ Native
Americans are also more likely to experience trauma, physical abuse,
neglect, and post-traumatic stress disorder.\10\ AI/ANs experience the
highest rates of suicide according to a 2020 SAMHSA study,\11\ with a
recent, February 2023 CDC report finding that teen girls are
experiencing record high levels of violence, sadness, and suicide
risk.\12\ Additionally, Native Americans experience some of the highest
rates of psychological and behavioral health issues as compared to
other racial and ethnic groups \13\ which have been attributed, in
significant part, to the ongoing impacts of historical trauma.\14\
---------------------------------------------------------------------------
\4\ U.S. Department of Health and Human Services, Centers for
Disease Prevention and Control, Provisional Life Expectancy Estimates
for 2021 (hereinafter, ``Provisional Life Expectancy Estimates''),
Report No. 23, August 2022, available at: https://www.cdc.gov/nchs/
data/vsrr/vsrr023.pdf, accessed on: October 13, 2022 (total for All
races and origins minus non-Hispanic American Indian or Alaska Native).
\5\ Id.
\6\ Broken Promises at 65.
\7\ Broken Promises at 65.
\8\ Broken Promises at 65.
\9\ Broken Promises at 65.
\10\ Broken Promises at 79-84.
\11\ Substance use And Mental Health Services Administration, Key
Substance Use and Mental Health Indicators in the United States,
Results from the 2020 National Survey on Drug Use and Health, available
at: https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/
NSDUHFF RPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf, accessed on:
March 22, 2023.
\12\ Centers for Disease Control and Prevention, Press Release:
U.S. Teen Girls Experiencing Increased Sadness and Violence, available
at: https://www.cdc.gov/media/releases/2023/p0213-yrbs.html, accessed
on: March 22, 2023.
\13\ Walls, et al., Mental Health and Substance Abuse Services
Preferences among American Indian People of the Northern Midwest,
Community Mental Health J., Vol. 42, No. 6 (2006) at 522, https://
link.springer.com/content/pdf/10.1007%2Fs10597-006-9054-7.pdf, accessed
on: November 20, 2022.
\14\ Kathleen Brown-Rice, Examining the Theory of Historical Trauma
Among Native Americans, Prof'l Couns, available at: http://
tpcjournal.nbcc.org/examining-the-theory-of-historical-trauma-among-
native-americans/, accessed on: November 22, 2022.
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The Resources Provided to the Indian Health Service
Although annual appropriations for IHS have consistently increased
since 2009, after adjusting for inflation and population growth, the
IHS budget has remained static in recent decades. In December 2018, the
U.S. Commission on Civil Rights' Broken Promises report found that
Tribal nations face an ongoing funding crisis that is a direct result
of the United States' chronic underfunding of Indian health care for
decades, which contributes to vast health disparities between Native
Americans and other U.S. population groups. We saw this crisis manifest
in the worst way possible during the COVID-19 pandemic, and now we see
it in the latest data and reporting.
Supplemental appropriations enacted during the pandemic were
historic investments for Indian Country. It cannot be lost to history
that the United States' swift action saved lives, but it must also be
clear that the IHS is so disproportionately underfunded by Congress
that a historic investment in response to a global virus still provided
less resources than the estimate of annual obligations for IHS services
in a single year--an amount collaboratively developed by the IHS
National Tribal Budget Formulation Workgroup (NTBFW). For comparison,
the latest enacted regular appropriations for IHS totals about $7
billion, or roughly 7 times less than the need-based estimate from the
Workgroup for FY 2023.
Imagine having only one day's worth of food for a week: for
generations. Imagine if the federal government asked you why you are so
hungry all the time when they `already gave you food;' why you can't
manage your groceries like someone with a full pantry when they took
nearly all of your resources. This staggering comparison underscores
the purposeful inequity that continues to result in American Indians
and Alaska Natives (AI/ANs) having some of the worst health outcomes of
any U.S. population. Surely, this cannot be the highest possible health
status promised by the United States in the IHCIA.
We understand and appreciate the need for Congress to embrace
fiscal restraint and balancing the national debt. However, our
ancestors have already prepaid for health care. This is not a new or
``nice to have'' program. IHS is an essential program that is the
fulfillment of sacred promises made to Tribal nations. It is time that
the U.S. Congress finally live up to these obligations and provide his
with adequate funding. We cannot expect the Indian health system to
improve when it does not have the resources it needs.
Just Like our Life Expectancy--U.S. Spending Policy is Stuck in the
Termination Era
Regardless of the Fund source or authorizing provision, the United
States is making an annual budget policy decision much like the dark
Termination Era policies that we pretend are behind us. Tribes and
their citizens originally had a system of health care delivery imposed
on them that was intentionally insufficient. Meanwhile, States and
local governments violated Tribes' tax jurisdiction, effectively
rendering Tribal nations without a way to fund basic infrastructure and
governance in often isolated and drastically reduced or wholly taken
lands.
As part of this imposed system, the resources provided to IHS have
been chronically underfunded and measurably unequal compared to
investments in other U.S. populations. We see this systematic
isolation, sovereign infringement, forced dependence, assimilation, and
termination in the annual appropriations process each year. We feel it
in our communities, and the outcomes and data have been placed before
us. We cannot expect Tribal communities' health to improve when they
are consistently starved for resources. Too often, Tribal nations are
trapped in a federal funding structure operating on the assumption that
only state governments are worthy of base funding, essentially,
assuming that we do not exist as jurisdictional sovereigns.
IHS Restoring Accountability Act--Step in the Right Direction
The IHS Restoring Accountability Act is well intentioned, and we
sincerely appreciate the work that the subcommittee has undertaken to
elevate the quality of care challenges at IHS. The legislation does
move the needle forward in some respects by expanding eligibility on
student loan repayment and the types of providers required to complete
Tribal culture and history training. Below, we offer some comments on
specific areas of the draft legislation.
SEC. 104: Clarification regarding eligibility for Indian
Health Service loan repayment program. Loan repayment
programs are smaller in scale, when considering their
availability to individuals, than loan forgiveness
programs. Expanding the eligibility requirements of the
Indian Health Service Loan Repayment Program (IHSLRP) to
include individuals willing to serve in half-time practice
and individuals with master's degrees in health care
programs who are also certified in business administration
and health-related fields could result in an increase of
applicants for employment. Additionally, this program
addresses the broad employment need and ongoing shortage of
employees by providing employment in exchange for
assistance with student loans rather than outright
forgiveness. To further address employment vacancies,
payments made through the IHS loan repayment program should
be tax exempt. Making this assistance tax exempt, as it is
for other federally-operated health care loan repayment
programs, would help address the workforce shortages at IHS
and throughout Indian Country.
SEC. 105: Improvements in Hiring Practices. We are glad to
see language in the bill that would improve on IHS' ability
to quickly hire medical professionals. Too often, we hear
stories of critical staff being lost to IHS because the
federal hiring process is too burdensome and bureaucratic.
We also agree with the language in the bill to provide
notice to Tribal nations on key personnel changes. NIHB
looks forward to working with Tribal nations and the
committee to think of creative ways to recruit and retain
medical professionals in a timely and efficient manner.
SEC. 107. Tribal Culture and History. The legislation
accurately addresses the need to strengthen and expand the
current training requirements for culture and history
provided in IHCIA. While issues regarding the creation of
training curriculum and consultation of Tribes on the
curriculum is not discussed, requiring the training be
mandatory and completed annually is a step in the right
direction. Expanding the list of individuals required to
complete the training to include employees, volunteers, and
contractors allows for more culturally aware and educated
employees providing care to every individual.
SEC 108. Staffing Demonstration Program. In this section
the bill would direct IHS to carry out a demonstration
project in which IHS may provide federally managed Service
units with staffing resources. Staffing is a key challenge
for health care providers everywhere. The creative
demonstration project at these facilities could impact
long-term staffing. However, we urge the Subcommittee to
work with Tribal nations to examine how this provision
could be more broadly expanded throughout the IHS and
Tribal health system. We also would urge that critical
resources are appropriated as part of this project.
SEC. 111. Enhancing Quality of Care in the Indian Health
Service. Section 111 requires HHS to consult with Indian
tribes, governing boards, Area offices, Service units, and
other stakeholders and establish best practices for
governing boards and Area offices. The language contained
in this section is thorough and will go a long way in
standardizing care for IHS patients and improving the
overall safety of the IHS. However, Congress must ensure
that it is fully funded for it to have a significant
impact.
Overarching Impacts:
Self-Governance Impact. Certain provisions in the bill would
require the IHS to adopt policies or practices that would impact
compacting and contracting pursuant to the Indian Self-Determination
and Education Assistance Act (ISDEAA). For example, Section 111 of the
draft bill requires the Secretary of HHS to establish best practices
provisions for governing boards and for Area offices and ultimately
``adopt'' those best practices, but there is no apparent shield from
the effects of that adoption for Tribes that enter into ISDEAA
agreements. On its face, the language appears to intend to address best
practices at IHS-operated Service units, but the definitions used for
the purpose of this section would include tribal health programs
operated by a Tribe or Tribal organization through an ISDEAA agreement.
Policies such as draft Section 111 put forward without an exemption for
Tribes or Tribal organizations that enter into ISDEAA agreements could
result in policies that infringe on the notions of Tribal sovereignty
and self-determination that were and are the fundamental policy
underpinnings of ISDEAA. Further, it undermines the government
efficiency aspects of ISDEAA compacts and contracts because it could
add another compliance layer to operations that are a return to the
United States telling Tribes how their treaty and trust rights should
be structured.
With respect to the impacts of this draft bill on contracting and
compacting under ISDEAA, it is important to note that draft section 111
is a single example of how well-intended policies may impact tribal
sovereignty and self-determination in ways that were not intended or
expected. NIHB is not an ISDEAA compact or contract negotiator for
Tribal nations, and the potential for impacts on self-determination or
`638' contacting and self-governance compacting expand beyond that of
draft Section 111 in the bill. One solution may be to include a section
in the bill that clarifies that none of the bill's provisions are
intended to have an impact on tribally-operated programs, unless a
tribe specifically agrees otherwise. NIHB continues to collaborate with
its partners to identify these provisions and propose solutions, but
the activity, again, underscores why outreach to Tribal nations from
this Committee is absolutely necessary to identify these concerns and
develop policy solutions on a government-to-government collaborative
basis.
Unfunded mandates. This draft bill has twenty-four sections, seven
of the sections specifically add additional reporting requirements for
IHS and five others establish additional programs to be created and
implemented by either HHS or IHS. Many sections, like section 111:
Enhancing Quality of Care in the Indian Health Service, add more than
one additional reporting requirement for multiple different agencies
including but not limited to The Department of Health and Human
Services, IHS, the Centers for Medicare and Medicaid Services, and GAO.
While many of the reporting requirements and programs outlined in the
draft bill are well intentioned, and likely needed, Congress must
provide appropriated funds for these actions to occur. Additional
transparency from IHS is essential in improving care and ensuring that
the scarce dollars appropriated to IHS are well spent. But time and
time again, Congress enacts legislation that places yet another barrier
on Indian Country receiving access to quality healthcare. Mandatory
appropriations for the IHS are consistent with the trust responsibility
and treaty obligations reaffirmed by the United States in IHCIA. It's
time for Congress to provide essential appropriated funding, otherwise
this legislation will be another set of unfunded challenges at IHS.
Additional Key Policy Recommendations:
In addition to the comments below, we would like to reiterate some
policy recommendations to improve and enhance the Indian Health
Service.
Expansion of Tribal Self Governance for the Special
Diabetes Program for Indians (SDPI): Tribes and Tribal
organizations have repeatedly called for a change to the
Special Diabetes Program for Indians (SDPI) program
structure to allow recipients the option to receive funding
through 638 contracts and compacts which would allow for
self-determination and self-governance. This would
establish SDPI as an essential health service, remove the
culturally inappropriate competitive grant structure,
prevent the unnecessary federal administrative burden, and
support Tribal sovereignty by transferring control of the
program directly to Tribal governments.
Data sharing with IHS operated sites and TECs: CDC data from
2021 show that rates of syphilis are increasing exponentially for
American Indians and Alaska Natives nationwide, far outpacing the
national average. Despite these high rates, Tribal Epidemiology Centers
have not been told the number of infant deaths from syphilis by any
state or federal agency. Up to 40% of infants born to mothers with
untreated syphilis can be stillborn or die. Great Plains Tribal
Leaders' Health Board and its Tribal Epi Center along with Great Plains
Area Tribes have asked, repeatedly, for more information around the
syphilis outbreak to help better monitor and address the devastating
syphilis rates in the region. But it has not be provided by IHS.
Without this data, TECs and Tribes cannot target prevention and
education activities; provide testing and treatment to those who need
it most; or ensure that not one more Native baby is born with
congenital syphilis.
This is just one example of a serious issue. This happens time
and again where our Tribes and TECs are not given access to data that
they are entitled to receive by law. It is critical that leadership at
the highest level take immediate action.
Authorize full mandatory funding for all IHS programs.
Through its coerced acquisition of land and resources and
genocide destruction of cultures and peoples the United
States formed a fiduciary relationship with Tribal nations
whereby it has created a trust relationship to safeguard
Tribal rights, lands, and resources. As part of this
coerced exchange, Congress has continuously reaffirmed its
duty to provide for Indian health care. Unfortunately,
Tribal nations face an ongoing health crisis directly
resulting from the United States' chronic underfunding of
Indian health care for decades. This contributes to ongoing
health and persistent inequities and disparities. Mandatory
appropriations for the IHS are consistent with the trust
responsibility and treaty obligations reaffirmed by the
United States in IHCIA. Even today, 13 years after IHCIA
was permanently enacted, many provisions of IHCIA remain
unfunded and without implementation. Full and mandatory
funding must include the full implementation of all
authorized IHCIA provisions.
Until Congress passes full mandatory funding for all IHS programs,
the NIHB urges Congress to pass the following incremental funding
measures:
a. Authorize mandatory funds for Contract Support Costs and 105(l)
Lease Payments.
As the Appropriations Committee has reported for years,
certain IHS account payments, such as Contract Support Costs and
Payments for Tribal Leases, fulfill obligations that are typically
addressed through mandatory spending. Inclusion of accounts that are
mandatory in nature under discretionary spending caps has resulted in a
net reduction on the amount of funding provided for Tribal programs
and, by extension, the ability of the federal government to fulfill its
promises to Tribal nations.
b. Permanently Authorize discretionary advance appropriations.
Advance appropriations for the IHS marks a historic paradigm
shift in the nation-to-nation relationship between Tribal nations and
the United States. With advance appropriations, AI/ANs will no longer
be uniquely at risk of death or serious harm caused by delays in the
annual appropriations process. NIHB urges Congress to pass a bill
authorizing annual advance appropriations for all areas of the IHS
budget and providing for increases from year to year that adjust for
inflation, population growth, and necessary program increases. NIHB
supports advance appropriations until full, mandatory appropriations
are enacted.
c. Protect the IHS budget from ``sequestration'' cuts.
The IHS budget remains so small in comparison to the national
budget that spending cuts or budget control measures would not result
in any meaningful savings in the national debt, but it would devastate
Tribal nations and their citizens. As Congress considers funding
reductions in FY 2024, IHS must be held harmless. As we saw in FY 2013
poor legislative drafting subjected our tiny, life-sustaining, IHS
budget to a significant loss of base resources. Congress must ensure
that any budget cuts--automatic or explicit--hold IHS and our people
harmless.
d. Authorize federally-operated health facilities and IHS
headquarters offices to reprogram funds at the local level
in consultation with Tribes.
The Indian Self-Determination and Education Assistance Act
(ISDEAA) authorized Tribal nations to take greater control over their
own affairs and resources by contracting or compacting with the federal
government to administer programs that were previously managed by
federal agencies. This includes the ability to develop and implement
their own policies, procedures, and regulations for the delivery of
these services. Tribal nations may also receive direct services from
the IHS. Unfortunately, some of the flexibility that makes ISDEAA so
cost effective at delivering services is not available at the local
level when direct services are provided by the IHS. Fundamentally, the
ability to direct resources is one of Tribal sovereignty and self-
determination. Just because a Tribe chooses to receive direct services
from IHS does not mean it forfeits these rights. IHS must have greater
budget flexibility, especially at the local service unit level to
reprogram funds to meet health service delivery priorities, as directed
by the Tribes who receive services from that share of the IHS funding.
e. Authorize Medicaid reimbursements for Qualified Indian Provider
Services.
In 1976, Congress gave the Indian health system access to the
Medicaid program in order to help address dramatic health and resources
inequities and to implement its trust and treaty responsibilities to
provide health care to AI/ANs and today, Medicaid remains one of the
most critical funding sources for the Indian health system. In order to
ensure that States not bear the increased costs associated with
allowing Indian health care providers access to Medicaid resources,
Congress provided that the United States would pay 100 percent of the
costs for services received through Indian health care providers (100
percent FMAP). While Congress provided equal access to the Medicaid
program to all Indian health care providers, in practice access has not
been equal. Because States have the option of selecting some or none of
the optional Medicaid services, the amount and type of services that
can be billed to Medicaid varies greatly state by state. So, while the
United States's trust and treaty obligations apply equally to all
tribes, it is not fulfilling those obligations equally through the
Medicaid program. To further the federal government's trust
responsibility, and as a step toward achieving greater health equity
and improved health status for AI/AN people, we request that Congress
authorize Indian health care providers across all states to receive
Medicaid reimbursement for a new set of Qualified Indian Provider
Services. These would include all mandatory and optional services
described as ``medical assistance'' under Medicaid and specified
services authorized under the IHCIA when delivered to Medicaid-eligible
AI/ANs. This would allow all Indian health care providers to bill
Medicaid for the same set of services regardless of the state they are
located in. States could continue to claim 100 percent FMAP for those
services so there would be no increased costs for the states for
services received through IHS and tribal providers.
Conclusion
For the last 47 years, the United States has had a policy of
ensuring the highest possible health status for Indians and to provide
all resources necessary to affect that policy. Unfortunately, those
responsibilities and legal obligations remain unfulfilled and Indian
Country remains in a health crisis. Clearly, the status quo isn't
working.
Time will tell if today's hearing on the challenges and
opportunities for improving healthcare delivery in Tribal communities
marked the beginning of significant change, or the continuation of the
status quo. The challenges are many, but most are equally matched by
the opportunities and solutions already identified by Tribal leaders,
Congresses, and Administrations past and present.
There is a way forward if Congress can overcome perhaps the
greatest remaining challenge: political will. NIHB recognizes that the
recommendations offered in this testimony will require coordination
with other committees of jurisdiction, and we stand ready to help with
that effort. But the heavy lifting must be borne by this Subcommittee.
No other subcommittee in the House is as focused on Indian affairs as
this one. At the same time, as noted earlier, we encourage Congress to
support an NSC process that would allow for Tribes to advocate for
needed changes to IHCIA with one united voice. This process is critical
to ensure that the changes only improve, and do not cause unintentional
harm for the Indian health system. For the sake of our People, we hope
this Subcommittee in the 118th Congress is up to the challenge.
Thank you again for the opportunity to offer testimony on this
legislation today. We are happy to answer any questions you might have.
______
Questions Submitted for the Record to Mr. Lee Spoonhunter, Billings
Area Representative, National Indian Health Board
Mr. Spoonhunter did not submit responses to the Committee by the
appropriate deadline for inclusion in the printed record.
Questions Submitted by Representative Westerman
Question 1. Previous versions of the Restoring Accountability in
the Indian Health Service Act included a section on medical chaperones.
Is there still a need for medical chaperones for patients at IHS
facilities? And if so, please elaborate on what language should be
added to this discussion draft to address the issue.
Question 2. Recruitment and retention of health care personnel are
two issues this committee has heard about time and time again,
especially in rural areas. The entire health care system faces
challenges of hiring and retaining medical professionals.
2a) Anecdotally, what barriers do you know medical professionals
face to work at either IHS or tribally run health care programs?
2b) What have you seen in tribally run health care programs
regarding improvements to hiring and recruitment that could help IHS
fill their staff vacancies and improve employee retention?
2c) What sections of this discussion draft could help with
recruitment and retention of personnel the most?
Question 3. There have been reports regarding the lack of
accountability when it comes to IHS employees and misconduct.
3a) Anecdotally, can you provide any examples of complaints toward
IHS medical staff not being taken seriously by IHS officials?
3b) Are you aware of any incidents that have not been previously
reported where an IHS employee retained their position despite
complaints being raised against them?
3c) Are the protections provided in this discussion draft enough
for IHS employees to raise objections and be certain they are safe to
do so?
Question 4. NIHB raised the question of reimplementing a tribal
advisory committee like the National Steering Committee to Reauthorize
of the Indian Health Care Improvement Act (IHCIA) that had previously
advised the federal government about changes to the IHCIA, prior to its
permanent reauthorization.
4a) Would your organization be supportive of that sort of committee
being established? What if the tribal leaders who serve on the
committee would serve without pay?
4b) What other advisory committees or councils that are currently
established in HHS or IHS that could be used to provide the expertise
the National Steering Committee previously provided?
4c) What further ways aside from a national steering committee may
be beneficial to institute so IHS will have more input from tribes on
how to improve IHS policies and procedures?
Question 5. Concerns were raised in NIHB written testimony about
the discussion draft affecting tribally run health programs that have
been compacted or contracted out from IHS.
5a) What sections of this discussion draft could most affect
tribally operated health programs and how?
5b) What language do you think should be included to reduce that
effect?
5c) Are there aspects of this discussion draft that would improve
tribal autonomy and control over tribally run health programs?
Question 6. From your perspective, what regulations and official
guidance from IHS cause the largest challenges for tribal members
seeking care? What about for tribes compacting or contracting out
health care services from IHS?
Question 7. In your testimony, NIHB raised concerns regarding
unfunded mandates and programs included in this discussion draft.
7a) Does NIHB have concerns with these programs specifically, or
are the concerns only about funding?
7b) If IHS has already begun to institute some of these policies
and programs with their current funding, does that change NIHB's
position?
Questions Submitted by Representative Leger Fernandez
Question 1. A common theme throughout the hearing was the need for
Congress to hear directly from tribes and tribal organizations across
the country on any policies designed to improve direct or indirect IHS
care for American Indians and Alaska Natives.
1a) How do you believe Congress should consult with Tribes on their
unique experiences and perspectives to inform potential legislation to
improve the Indian Healthcare Improvement Act (IHCIA)?
1b) One recommendation put forward was for Congress to support a
National Steering Committee (NSC) process to examine necessary reforms
to IHS and IHCIA. How do you believe Congress can best support Tribes
in such processes to ensure policy outcomes are led by tribal leaders?
______
Ms. Hageman. Thank you, Mr. Spoonhunter, for your
testimony.
The Chair now recognizes Ms. Jerilyn Church for 5 minutes.
STATEMENT OF JERILYN CHURCH, EXECUTIVE DIRECTOR, GREAT PLAINS
TRIBAL LEADERS HEALTH BOARD, RAPID CITY, SOUTH DAKOTA
Ms. Church. Good afternoon, Chairwoman Hageman, Ranking
Member Fernandez, distinguished members of the Subcommittee,
and Representative Johnson, thank you so much for the
opportunity to be here this afternoon and to share my thoughts
and testimony on the discussion draft for ``Restoring
Accountability in the Indian Health Service.''
On behalf of the Great Plains Tribal Leaders Health Board,
my name is Jerilyn Church. I am a member of the Cheyenne River
Sioux Tribe. I serve as the President and CEO of the Great
Plains Tribal Leaders Health Board and the Oyate Health Center
in Rapid City, South Dakota.
We serve as a liaison between the tribes in the Great
Plains, North Dakota, South Dakota, Nebraska, and we have one
member tribe in Iowa, and we represent the tribes on various
Health and Human Services divisions, including the Indian
Health Service.
In our region, the Indian Health Service is the primary
source of healthcare for nearly 150,000 American Indians and
Alaska Natives in the Great Plains area. So, we are acutely
aware of the difficulties and challenges within the Indian
Health Service and of the need to improve healthcare delivery
and health outcomes for Indian people in our communities. In
fact, this past spring, I had the opportunity to testify before
this Subcommittee on some of these challenges and appreciate
the members of this Subcommittee placing an emphasis on
improving IHS and its operations.
This draft legislation brings up important improvements,
improving IHS management, the whistleblower protections,
provision for housing, strengthening training requirements, the
establishment of a compliance assistance program and, of
course, providing for transparency in CMS surveys. However, we
believe that there are additional opportunities to improve the
language.
One of the concerns that we have is that in order to make
changes and improvements, IHS is already under-resourced
significantly, so any changes and improvements that are put
forward need to be funded adequately to make meaningful change.
We don't want it to become an issue where there are additional
red tape or additional reporting requirements that take away
from healthcare delivery, but strengthen already existing
provisions that the Indian Health Service is required to
provide that they may not be. We don't want it to be so
burdensome that we end up just adding additional barriers to
improve healthcare.
We want to make sure that there is parity between tribally-
operated systems and direct service units that are managed
directly by IHS. That is a really important distinction. If the
language is not written in such a way that doesn't make those
distinctions, then there becomes an issue of tribes that are
already running their systems perhaps not being able to have
the same flexibilities that they had before and to be
innovative, which is one of the main reasons why tribes pursue
self-determination and self-governance so that they can work
outside of some of the parameters and red tape that Indian
Health Service sometimes has that gets in the way.
The Health Board is happy to work with the members of the
Subcommittee on suggestions. As my colleague here stated, one
of the most effective mechanisms for tribal leaders to lend a
voice and share their knowledge and wisdom was through the
national steering committee on the reauthorization of the
Indian Healthcare Improvement Act. So, we would strongly urge
the members of the Subcommittee to work with your colleagues to
direct Indian Health Service to reinstate that committee.
We thank you again for this opportunity to provide
testimony today. This is a critical issue in the Great Plains.
And, again, appreciate the opportunity to work with you to
improve healthcare delivery for our people. [Speaking Native
language.]
[The prepared statement of Ms. Church follows:]
Prepared Statement of Jerilyn LeBeau Church, Great Plains Tribal
Leaders Health Board
Thank you for this opportunity to present testimony on the
discussion draft of the ``Restoring Accountability in the Indian Health
Service Act of 2023'' on behalf of the Great Plains Tribal Leaders
Health Board (GPTLHB). GPTLHB serves as a liaison between the Great
Plains Tribes and the various Health and Human Services divisions,
including the Great Plains Area Indian Health Service (IHS), and works
to reduce public health disparities and improve the health and wellness
of American Indian people and Tribal communities across the Great
Plains. In our region, the Indian Health Service (IHS) is the primary
source of health care for nearly 150,000 American Indians/Alaska
Natives in the Great Plains Area. Of the six hospitals in the Great
Plains, five are managed directly by IHS. Of the 13 ambulatory health
clinics in the Great Plains Area, seven are managed entirely by a tribe
or a tribal organization under a Title I Self-Determination contract,
and five are managed directly by IHS. One is tribally managed through a
Title V Self Governance compact. In addition, the Indian Health Service
is responsible for two substance abuse treatment centers and supports
three urban health care programs.
Therefore, at GPTLHB, we are acutely aware of the difficulties and
challenges the IHS faces in improving healthcare delivery and
healthcare outcomes for Indian people in our communities. In fact, just
this spring, I testified before this Subcommittee on these current
challenges and opportunities. We appreciate the members of this
Subcommittee' placing an emphasis on improving the IHS and its
operations. This draft legislation raises several important issues and
proposes important improvements to the system, including;
improvements to IHS management;
employee whistleblower protections;
the provision for housing vouchers for recruitment and
retention;
strengthening the training requirements for tribal culture
and history;
the establishment of a compliance assistance program; and
providing for transparency in CMS surveys.
We do, however, have concerns about the legislation as drafted.
These include the need to make sure that the legislation does not
confer additional unfunded mandates on the already seriously under-
resourced IHS and that additional administrative requirements
(including agency reporting requirements) will not be so burdensome as
to take time and resources away from patient care. Concerning
improvements to IHS operations, ensuring the agency has sufficient
resources to do its job is the most crucial factor. It is also
essential to make sure that the legislation does not duplicate
authorities that IHS already has and that it maintains parity between
Tribally operated healthcare facilities and programs where appropriate.
It is also essential that Tribal facilities and programs are allowed to
opt into or not participate in certain IHS-specific requirements
imposed by the bill, such as the proposed uniform medical credentialing
system. As legislation is passed to ensure that it is implemented in
ways most appropriate to balancing IHS and tribal concerns, we
recommend that the legislation require negotiated rulemaking where
representatives of IHS and tribes around the country can meet together
to determine the most effective implementation.
GPTLHB is happy to work with the Members of the Subcommittee on
suggestions for improvements to the legislation as drafted, but the
discussion draft--and the issues underlying it--raise the larger
question of the process of including Tribal voices in potential
legislative improvements through amendments to the Indian Healthcare
Improvement Act (IHCIA). In the past, these legislative efforts would
primarily be driven by input from the knowledge, wisdom, and difficult
decision-making of the Tribal leaders who made up the National Steering
Committee (NSC) on the Reauthorization of the IHCIA. Now that the IHCIA
has been made permanent, that mechanism for critical Tribal input no
longer exists. We strongly urge the Members of the Subcommittee to work
with your colleagues to direct IHS to reinstate the NSC and to provide
sufficient appropriations to support its critical work.
Thank you for the opportunity to provide testimony today on this
critical issue and for your efforts to improve healthcare delivery to
all our People and communities.
______
Questions Submitted for the Record to Ms. Jerilyn Church, Executive
Director, Great Plains Tribal Leaders Health Board
Ms. Church did not submit responses to the Committee by the appropriate
deadline for inclusion in the printed record.
Questions Submitted by Representative Westerman
Question 1. Previous versions of the Restoring Accountability in
the Indian Health Service Act included a section on medical chaperones.
Is there still a need for medical chaperones? And if so, please
elaborate on what language should be added to this discussion draft to
address the issue.
Question 2. Recruitment and retention of health care personnel are
two issues this committee has heard about time and time again,
especially in rural areas. The entire health care system faces
challenges of hiring and retaining medical professionals.
2a) Anecdotally, what barriers do you know medical professionals
face to work at either IHS or tribally run health care programs?
2b) What have you seen in tribally run health care programs
regarding improvements to hiring and recruitment that could help IHS
fill their staff vacancies and improve employee retention?
2c) What sections of this discussion draft could help with
recruitment and retention of personnel the most?
Question 3. There have been reports regarding the lack of
accountability when it comes to IHS employees and misconduct.
3a) Anecdotally, can you provide any examples of complaints toward
IHS medical staff not being taken seriously by IHS officials?
3b) Are you aware of any incidents that have not been previously
reported where an IHS employee retained their position despite
complaints being raised against them?
3c) Are protections provided in this bill are enough for I-H-S
employees to raise objections and be certain they are safe to do so?
Question 4. NIHB raised the question ofreimplementing a tribal
advisory committee like the National Steering Committee to Reauthorize
of the Indian Health Care Improvement Act (IHCIA) that had previously
advised the federal government about changes to the IHCIA, prior to its
permanent reauthorization.
4a) Would your organization be supportive of that sort of committee
being established, even if it would require tribal leaders who serve on
the committee to serve without pay?
4b) What other advisory committees or councils that are currently
established in HHS or IHS that could be used to provide the expertise
the National Steering Committee previously provided?
4c) What further ways aside from a national steering committee may
be beneficial to institute so IHS will have more input from tribes on
how to improve IHS policies and procedures?
Question 5. In your testimony you mentioned the need to ensure that
this discussion draft does not duplicate authorities IHS already has.
5a) Could you elaborate further on that point and provide examples
of sections of the bill that may duplicate current IHS authorities?
5b) Are you aware of programs or policies within this discussion
draft that IHS is already working to implement or improve and, if so,
what are they?
Question 6. From your perspective, what regulations and official
guidance from IHS cause the largest challenges for tribal members
seeking care? What about for tribes compacting or contracting out
health care services from IHS?
Question 7. During the hearing, you brought up concerns with the
medical credentialing aspect of the legislation as well as tribal
health program autonomy.
7a) What specific medical credentials could IHS institute that
could be detrimental to tribally run medical facilities?
7b) Could you elaborate on how the discussion draft should balance
tribal autonomy and ensuring parity of care and credentialing occurs
across both IHS and tribally run health programs?
7c) Is there anything else Congress should need to know to make the
best policy decisions on this topic?
Questions Submitted by Representative Leger Fernandez
Question 1. A common theme throughout the hearing was the need for
Congress to hear directly from tribes and tribal organizations across
the country on any policies designed to improve direct or indirect IHS
care for American Indians and Alaska Natives.
1a) How do you believe Congress should consult with Tribes on their
unique experiences and perspectives to inform potential legislation to
improve the Indian Healthcare Improvement Act (IHCIA)?
1b) One recommendation put forward was for Congress to support a
National Steering Committee (NSC) process to examine necessary reforms
to IHS and IHCIA. How do you believe Congress can best support Tribes
in such processes to ensure policy outcomes are led by tribal leaders?
______
Ms. Hageman. Thank you, Ms. Church. And we all agree that
this is a very important issue, so, again, we appreciate you
being here.
I believe they have called votes, but we are going to go
ahead and have Mr. Carl do his 5 minutes of questioning just to
make sure that we can get those in. So, Mr. Carl, if you would
please proceed with 5 minutes of questioning.
Mr. Carl. Thank you, Madam Chairman, and thank you to the
panel for coming and speaking and taking your time. Mr.
Spoonhunter, it is always great to see you. We have developed a
friendship over time. My question is targeted at you, but let
me run through a list here real quick.
As you are aware, the Indian Health Services play a
critical role in providing healthcare to the Native American
community. It is evident that the Indian Health Services has
been struggling with issues like substandard medical care, high
staff vacancy rate, and I think we were around 50 percent a
while ago when I heard some numbers talked about, and
inadequacy of the facilities, making it hard for them to
deliver quality healthcare to those who need it the most.
The Restoring of Accountability in the Indian Health
Services Act aims to address various problems. One is the
inability to retain quality healthcare professionals. I know
that the Federal Government always feels like they have all the
answers. I am one of those that don't believe that. I grew up
digging ditches and working with my hands, and most of the
answers, you have to go to the field to actually figure that
out and talk to the people and learn what the problems truly
are.
So, my question to you, in your experience, what measures
do you believe this Act should include to effectively improve
overall state of healthcare delivery in the Indian Health
Services?
Mr. Spoonhunter. Thank you, Representative Carl, it is
always good to see you here on the Hill. At Wind River, we have
a very unique situation. We have two tribes there: the Eastern
Shoshone and the Northern Arapaho. The Eastern Shoshone, the
majority of their tribal members go to a direct IHS funded
facility which was built in the 1800s, that is still open today
and still needs to be replaced. That is the standard that
hopefully this bill will cover.
And then you have the Northern Arapaho who have taken the
Arapaho Clinic there and they have 638 self-determination, took
the resources from IHS and developed quality healthcare for our
people there without the bureaucratic red tape that IHS has in
place that sometimes prevents our tribal members from receiving
the adequate quality care that they need. Through self-
governance, we are able to have competitive wages for the
medical team, doctors, nurses, all of the staff, with the
surrounding Fremont County that we live in.
And we are also able to provide insurance and a 401(k)
package that is a lot better than what IHS can provide. So, we
retain a lot of our doctors, and a lot of our doctors have come
and stayed with us. But it is through self-governance that we
are so successful.
We have been able to take one clinic in of our communities
and open up two clinics, one in Ethete, Wyoming and the one in
Riverton, Wyoming which is on the neighboring town of the
reservation. The Riverton Clinic is more visited than the
reservation clinics because a lot of our tribal members have a
lack of housing, so they have to stay in a neighboring town.
But the answer to your question is, it is through self-
governance and through 638 that we are able to use our tribal
sovereignty to provide better care to our tribal members, and
we encourage our Eastern Shoshone tribal counterparts to do the
same, and I know they are in that process now. But it is
through, again, I say the bureaucratic red tape of IHS and what
they have to endure that sometimes the quality of care for
tribal members and Native American people gets lost in all of
the government rules and regulations that IHS has to go
through, and that is unfortunate.
It is unfortunate because we should be talking about
quality healthcare for our people and a lot less rules and
regulations. But with this bill, we look forward to continued
dialogue so that we can get it right. We want to work with
Congress and let's get it right once and for all.
Mr. Carl. Thank you, Mr. Spoonhunter. Might I make a
suggestion? I would love to do a CODEL and go out and look at
some of these places that these tribal members actually pick
for us to look at, not for IHS to choose for us. I would like
to go out there and look at it. My background is healthcare, I
spent 35 years in it, in managing, so I would love to go out
and look and see what they are actually dealing with. And if we
could do that as a group, that would be great.
Ms. Hageman. I think that is an excellent idea and we will
work with staff to see if that is something that we can put
together.
Mr. Carl. I yield back my time. Thank you.
Ms. Hageman. Thank you very much. The Chair now recognizes
Ms. Leger Fernandez for her 5 minutes of questioning.
Ms. Leger Fernandez. Thank you so much for pointing out
really the task before us, which is just how do we go about,
(1), coming up with the ideas for the bill. And the issue of
what I am hearing from you, Mr. Spoonhunter, is that going back
to the system of using the CSA, and I heard, Ms. Church, you
say that as well. Do you agree with that, too? OK.
So, the process that you would like to see is to make sure
that we are able to gather input from the wide range of tribes
and tribal communities receiving healthcare.
Mr. Spoonhunter, the idea is that it is very distinct. Like
in one reservation, you have a 638 compacted facility and then
a direct, and what you see is very different. And I have helped
build and set up health boards, and oh my god, it is amazing
when you can end up having a joint venture facility, being able
to staff it like it should be instead of, as you pointed out,
frozen in time, was it 1927 or something? And that is key in
being able to make those distinctions. So, I think that that is
something that we really need to do.
So, this idea of a consultation process, can you just
explain a little bit more how you would like that to look?
Ms. Church. Yes, I will throw my two cents in there. The
national steering committee that was established when the
Indian Healthcare Improvement Act was reauthorized, and that no
longer exists, but that body that consisted of tribal
representation, tribal leaders from across all of Indian
Country was the driving force. Their voice was the driving
force to make the recommendations for what needed to happen to
improve and update the Indian Healthcare Improvement Act.
At that time, that body, they were the primary authors.
There are still some things that could be finessed with that,
but it was tribal leadership, not Indian Health Service, that
was driving those changes and that is what made the Indian
Healthcare Improvement Act so much more effective and brought
the opportunities that we have today.
Ms. Leger Fernandez. And in essence it was tribal
leadership and also not Congress, right? We were listening to
what was coming out of this process.
Ms. Church. Exactly.
Ms. Leger Fernandez. Which was lengthy. If we don't act
quickly, I mean, every day that we wait to get better services,
it is heartbreaking, somebody dies, right, somebody is ill.
Mr. Spoonhunter, did you want to add something?
Mr. Spoonhunter. Yes, thank you, Representative Fernandez.
As a 638 and as a self-governance, it is the tribal leaders who
oversee the clinic. We are responsible for the day-to-day
activities of that clinic, as where in an IHS direct service we
are not. And Ms. Church hit on a key point. Come to the tribal
leaders, come to us, and when you are doing the consultation of
this bill, and in working through what we need to fix, because
it is not IHS that needs to fix it. As tribal leaders, the
sovereign nations, we know what we need to do for our people to
provide better healthcare. Just give us the opportunity. Thank
you.
Ms. Leger Fernandez. Thank you. And, Ms. Church, you are in
a very interesting position because you are in the process
right now of building the joint venture facility, which meant
you had to come up with the money, right? I have helped finance
those. And not every tribe is going to be in that position. So,
what is your recommendation to us for those tribes who are not
in a position to finance a facility and/or compete for those
joint venture slots?
Ms. Marchand. I am not sure what my recommendation would
be. Obviously, more money. That is always a key. But, again, I
think as those to the left of me have said, by going to those
tribes and listening to what their needs are, possibly you may
not find out it is as expensive as what they need.
So, I would say just going with the consultation and just
finding out like what other programs or things that maybe we
could do for them that may not be a joint venture or that
magnitude but things that could improve their Indian Health
Services through appropriations.
Ms. Leger Fernandez. OK, thank you so much, and we will
submit any additional questions in writing because I think
there is a lot of material that you have given us that we need
to flesh out, so I truly appreciate it.
Ms. Hageman. Thank you. The Chair now recognizes Mr.
Johnson for 5 minutes of questioning.
Mr. Johnson. You are so very gracious, ma'am, thanks. I
won't take the 5 minutes because you may want to get in before
votes as well.
But first off, Ms. Church, I would just validate everything
you were saying about being under-resourced. That is clearly a
big part of the issue. I did like the distinction you drew, I
think an important one between tribally-administered facilities
and those that are directly administered.
Give us a little more meat on that bone. How specifically
could we help strengthen this legislation by calling out those
important distinctions?
Ms. Church. Thank you. Yes, so I can give examples probably
better than getting into the details. For instance, I think one
of the recommendations in the bill was around credentialing and
having a uniform credentialing process. I think that would work
for Federal facilities that are managed directly by IHS. Some
of our programs that are run by tribes, they may partner with
another health system that may not be part of the Indian Health
Service. So, there is flexibility that tribes and tribal
organizations such as ours have to get creative with how to
make our system work better.
Another example is our tribal sponsorship. One of the ways
that Oyate Health Center helps to make our dollars go further
is we have a tribal sponsorship program. We take a portion of
our PRC dollars, and we buy insurance for a group of our
beneficiaries who may not be eligible, meet the criteria for
Medicaid, but don't have insurance. So, that is something that
the Federal Government cannot do that we can do. We can
purchase tribally-sponsored insurance that brings revenue back
into our system and it helps those PRC dollars go a lot
further. Those are a couple of examples.
Mr. Johnson. Oh, it is wonderful, and South Dakota is so
grateful for your leadership, ma'am, thanks.
And, Madam Chair, I yield back.
Ms. Hageman. Thank you for that. The Chair now recognizes
myself for 5 minutes of questioning.
First of all, Mr. Spoonhunter, you were speaking my
language in your testimony when you talked about the challenges
associated with the over-regulation that comes from the IHS.
What I would like to do, because I would think that it might
take us 6 or 7 hours if I were to ask you all of the
regulations that create problems for you, I would like to have
an opportunity to engage with you, since I represent the state
of Wyoming, where you can perhaps identify for us, and we will
send some written questions to this effect, that maybe you can
identify some of those regulations that cause the largest
challenges, maybe for one or two of your facilities, maybe for
all of your facilities.
But I am a strong advocate, No. 1, in making sure that you
have the autonomy to do what you need to do to take care of
your tribal members, because I think you are going to be better
at it than anybody out of Washington, DC. I am not trying to
disparage anyone, I am just saying you care about the people
there more than anyone here ever will, and it is just the
reality. The closer you are to the situation, the more
effective you are going to be.
So, I would like to identify some of those rules and
regulations coming out of IHS, or HHS, or wherever it may be
coming from that are causing the challenges that you have, and
let's see if we can fix some of those as well.
In your testimony, Mr. Spoonhunter, you stated that the
NIHB looks forward to working with Tribal Nations and the
Committee to think of creative ways to recruit and retain
medical professionals in a timely and efficient manner. I would
also throw in there perhaps dental professionals because that
is one of the other issues that has been brought to us
repeatedly is the challenges of finding dental care for our
tribal members.
So, the question I have for you is, could you please expand
on what those creative ways could be and how they could align
with the goals of the IHS staff recruitment and retention
related to this particular draft legislation?
Mr. Spoonhunter. Thank you, Chairwoman. On the staffing
levels that the IHS has had a problem with filling, again, yes,
underfunding positions is a problem within IHS. We all know
that. But that would just be a Band-Aid fix. We really need to
sit down, with self-governance, at Wind River, we were able to
get a person that would recruit our physicians, providers,
nurses, and vet them through a very rigorous process, and we
were able to also offer housing through the self-governance and
through third-party billing.
As you know, in my area, the Billings area that I
represent, Fort Peck cannot keep a doctor because there is no
housing there. And I know this bill covers a housing voucher in
a similar way, but we were able to also bring on the signing
bonus for providers through the third-party billing. But,
again, it is a lot of bureaucracy that IHS has to go through to
hire. It takes a whole process.
I mean, we were talking today about an administrator
position in one of the IHS service units that they had to raise
the wage in order to hire someone to meet the qualifications of
that job, and now that job has to wait 90 days because of IHS
rules. That is an example of the bureaucracy that we have to
wade through in order to hire someone of that administrative
magnitude that will help direct these facilities.
So, again, it is a matter of allowing the tribes to come in
and be part of that process and asking IHS these necessary
questions that Congress I am sure that you have asked IHS, why
does it take you so long to hire someone, why are you not able
to recruit and keep someone in that position. Those things are
very critical.
And you talk about the dentist program. We are all
scrambling to try to find dentists and retain dentists
throughout Indian Country, and I know IHS is doing the same
thing. But what can we do on a creative side that some of the
self-governance 638 programs have done to recruit dentists?
Let's look at their plans and what they did, because as tribes
we are resourceful.
We are resourceful because we take what we have, and we
make it work. And I think that the plans, like my colleague
here Ms. Church said, have IHS sit down at the table with the
tribal leaders and learn from us. We have taken self-governance
638 and we have done it better than what IHS could ever do.
Ms. Hageman. OK. I appreciate that, and we want to learn
from you. Ms. Marchand and Ms. Church, I would request the same
thing, if you have ideas of how we can streamline this and
address it.
One of the things in Wyoming, because we are the least
populated state in the nation, and we only have one university,
and we don't provide either dental training or medical
training, so we have arrangements with other universities. We
send our physicians to the University of Washington, UW,
another UW, for example, and then we do the same thing with
dental care, and then they come back to Wyoming and must spend,
I believe it is, a minimum of 5 years practicing in the state
of Wyoming, but they can get in-state tuition when they are
going out of state to be able to receive that training.
I don't know if those are the kinds of programs that we
could do with our tribal members as well, but I am absolutely
willing to look at innovative ways to address this issue. I
know Mr. Johnson is. I am extremely proud to have him with us
on the Committee today for the hearing to talk about these
things.
We do have to leave and go vote, so what I am going to say
is that I really want to thank all of you for being here. I
wish we could have spent a bit more time together. It is kind
of a strange time for all of us. You have provided extremely
valuable testimony. We are going to follow up with you because
we do have additional questions.
The members of the Committee may have some additional
questions for the witnesses, and we will ask you to respond to
these in writing. Under Committee Rule 3, members of the
Committee must submit questions to the Committee Clerk by 5
p.m. on Tuesday, August 1, 2023. The hearing record will be
held open for 10 business days for these responses.
And if there is no further business, without objection, the
Committee stands adjourned.
[Whereupon, at 3:14 p.m., the Subcommittee was adjourned.]
[ADDITIONAL MATERIALS SUBMITTED FOR THE RECORD]
Submission for the Record by Rep. Grijalva
Statement for the Record
United South and Eastern Tribes
Sovereignty Protection Fund
on H.R.____, ``Restoring Accountability in the Indian
Health Service Act of 2023''
The United South and Eastern Tribes Sovereignty Protection Fund is
pleased to provide testimony for the record of the House Natural
Resources Subcommittee on Indian and Insular Affairs legislative
hearing on the discussion draft of H.R. ____, The Restoring
Accountability in the Indian Health Service Act of 2023. As we have
indicated in the past, we can appreciate the intent of legislation to
address shameful failures in the execution of the Indian Health
Service's (IHS) trust and treaty obligations to deliver quality health
care to Tribal Nations and our citizens. However, it is disingenuous to
ignore the decades of chronic underfunding of the agency and how IHS'
lack of resources contributes in large part to these failures. In
addition, although we recognize that this bill remains a discussion
draft, we underscore the need for thorough Tribal consultation to occur
prior to further consideration. As written, we join our partners in
expressing several concerns about the bill's provisions. Although USET
SPF supports reforms that will improve the quality of service delivered
by the IHS, we continue to underscore the obligation of Congress to
meet its trust and treaty obligations by providing full and mandatory
funding to IHS and support additional innovative legislative solutions
to improve the Indian Health System.
USET SPF is a non-profit, inter-tribal organization advocating on
behalf of thirty-three (33) federally recognized Tribal Nations from
the Northeastern Woodlands to the Everglades and across the Gulf of
Mexico.\1\ USET SPF is dedicated to promoting, protecting, and
advancing the inherent sovereign rights and authorities of Tribal
Nations and in assisting its membership in dealing effectively with
public policy issues.
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\1\ USET SPF member Tribal Nations include: Alabama-Coushatta Tribe
of Texas (TX), Catawba Indian Nation (SC), Cayuga Nation (NY),
Chickahominy Indian Tribe (VA), Chickahominy Indian Tribe--Eastern
Division (VA), Chitimacha Tribe of Louisiana (LA), Coushatta Tribe of
Louisiana (LA), Eastern Band of Cherokee Indians (NC), Houlton Band of
Maliseet Indians (ME), Jena Band of Choctaw Indians (LA), Mashantucket
Pequot Indian Tribe (CT), Mashpee Wampanoag Tribe (MA), Miccosukee
Tribe of Indians of Florida (FL), Mi'kmaq Nation (ME), Mississippi Band
of Choctaw Indians (MS), Mohegan Tribe of Indians of Connecticut (CT),
Monacan Indian Nation (VA), Nansemond Indian Nation (VA), Narragansett
Indian Tribe (RI), Oneida Indian Nation (NY), Pamunkey Indian Tribe
(VA), Passamaquoddy Tribe at Indian Township (ME), Passamaquoddy Tribe
at Pleasant Point (ME), Penobscot Indian Nation (ME), Poarch Band of
Creek Indians (AL), Rappahannock Tribe (VA), Saint Regis Mohawk Tribe
(NY), Seminole Tribe of Florida (FL), Seneca Nation of Indians (NY),
Shinnecock Indian Nation (NY), Tunica-Biloxi Tribe of Louisiana (LA),
Upper Mattaponi Indian Tribe (VA) and the Wampanoag Tribe of Gay Head
(Aquinnah) (MA).
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Chronic Underfunding Leads to IHS Failures
As the Subcommittee is well aware, Native peoples have endured many
injustices as a result of federal policy, including federal actions
that sought to terminate Tribal Nations, assimilate Native people, and
to erode Tribal territories, learning, and cultures. This story
involves the cession of vast land holdings and natural resources,
oftentimes by force, to the United States out of which grew an
obligation to provide benefits and services--promises made to Tribal
Nations that exist in perpetuity. These resources are the very
foundation of this nation and have allowed the United States to become
the wealthiest and strongest world power in history. Federal
appropriations and services to Tribal Nations and Native people are
simply a repayment on this perpetual debt.
At no point, however, has the United States honored these sacred
promises; including its historic and ongoing failure to prioritize
funding for Indian Country. The chronic underfunding of federal Indian
programs continues to have disastrous impacts upon Tribal governments
and Native peoples. As the United States continues to break its
promises to us, despite its own prosperity, Native peoples experience
some of the greatest disparities among all populations in this country
and have for generations. It is no surprise, then, that the failures of
the federal government to fund the IHS have come into horrifyingly
sharper focus over the years and especially during the global pandemic.
Decades of broken promises, neglect, underfunding, and inaction on
behalf of the federal government left Indian Country severely under-
resourced and at extreme risk during this COVID-19 crisis.
These long-term challenges are multi-faceted and cannot be solved
overnight by one-size-fits-all reforms. Any efforts to reform IHS,
through Congressional action or otherwise, must be accomplished through
extensive Tribal consultation to reflect the complex challenges faced
by different Tribal communities, including Tribally-operated healthcare
facilities. Although USET SPF supports innovative legislative solutions
to improve the Indian Health System and recognizes that policy
improvements could be made, we continue to underscore the obligation of
Congress to meet its trust responsibility by providing full funding to
IHS. The federal trust responsibility obligates the federal government
to provide quality healthcare to Tribal Nations which can only be
accomplished when the Indian Health System is fully funded.
Full and Mandatory Funding for Federal Trust and Treaty Obligations
USET SPF celebrates and expresses its gratitude to this body for
its role in the historic achievement of advance appropriations for the
Indian Health Service (IHS). For the very first time, the agency's
clinical services will have budgetary certainty in the face of
continuing resolutions and government shutdowns. It is our expectation
that appropriators will continue to include language providing advance
appropriations for IHS beyond Fiscal Year (FY) 2024. We urge the
inclusion of all of IHS' budget line items in this mechanism, as well
as advance appropriations for all federal Indian agencies and programs
as next steps for this Congress. Despite its importance in the
stabilization of funding, however, we continue to view advance
appropriations as a temporary funding mechanism in our overall advocacy
for the full delivery of trust and treaty obligations.
Above all, the COVID-19 crisis has highlighted the urgent need to
provide full and guaranteed federal funding to Tribal Nations in
fulfillment of federal obligations. Because of our history and unique
relationship with the United States, the federal government's trust and
treaty obligations to Tribal Nations, as reflected in the federal
budget, is fundamentally different from ordinary discretionary spending
and should be considered mandatory in nature. Payments on debt to
Indian Country should not be vulnerable to year to year
``discretionary'' decisions by appropriators. Honoring the first
promises made by this country, in pursuing the establishment of its
great principled democratic experiment, should not be a discretionary
decision.
The Biden Administration's FY 2024 Request continues to propose a
shift in funding for IHS from the discretionary to the mandatory side
of the federal budget, including a 10-year plan to close funding gaps
and an exemption from sequestration, a move that would provide even
greater stability for the agency and is more representative of
perpetual trust and treaty obligations. Year after year, USET SPF has
urged multiple Administrations and Congresses to request and enact
budgets that honor the unique, Nation-to-Nation relationship between
Tribal Nations and the U.S., including providing full and mandatory
funding. We continue to ask that Congress join us in genuine
partnership, along with the Administration, to craft an enact this
necessary change. We firmly believe that full and mandatory funding for
the IHS is the only way to make meaningful inroads in the Agency's
challenges. To suggest otherwise ignores the primary source of these
challenges.
The FY 2024 Request also, once again, proposes mandatory funding
for Contract Support Costs and 105(l) leases--binding obligations--at
IHS, as well as the Bureau of Indian Affairs and the Bureau of Indian
Education. While we contend that all federal Indian agencies and
programs should be subject to mandatory funding, in recognition of
perpetual trust and treaty obligations, we continue to support the
immediate transfer of these lines to the mandatory side of the federal
budget. This will ensure that funding increases are able to be
allocated to service delivery, as opposed to the federal government's
legal obligations. The Senate Interior Appropriations Subcommittee
ultimately supported these important first steps in achieving mandatory
funding for Indian Country in its mark for FY 2023. We now call
Congress to work with Tribal Nations and the Administration fulfill its
responsibilities and work to ensure that this proposal is included in
any final FY 2024 appropriations legislation.
Expand Self-Governance Compacting and Contracting
The United States government bears a responsibility to uphold the
trust obligation, and that obligation includes upholding Tribal
sovereignty, self-determination, and self-governance. The Indian Self-
Determination and Education Assistance Act (ISDEAA) authorizes the
federal government to enter into compacts and contracts with Tribal
Nations to provide services that the federal government would otherwise
be obligated to provide under the trust and treaty obligations.
Although self-government by Tribal Nations existed far before the
passage of ISDEAA, Tribal Nations have demonstrated through ISDEAA
authorities since the bill's enactment that we are best positioned to
deliver essential government services to our citizens, including
through the assumption of federal program and services. Tribal Nations
are directly accountable to and aware of the priorities and problems of
our own communities, allowing us to respond immediately and effectively
to challenges and changing circumstances.
The success of self-governance under the ISDEAA is reflected in the
significant growth of Tribal self-governance programs since its
passage. In the USET region, the majority of our Tribal Nations engage
in self-governance compacting or contracting to provide essential
health care services. Across Indian Country, nearly two-thirds of
federally recognized Tribal Nations engage in self-governance, either
directly through the IHS or through Tribal organizations and
intertribal consortia. In Fiscal Year (FY) 2020, approximately 50% of
the IHS budget was distributed to self-governance Tribal Nations.
However, despite the success of Tribal Nations in exercising these
authorities under ISDEAA, the goals and potential of self-governance
have not yet been fully realized. Many opportunities still remain to
improve and expand self-governance, particularly within HHS. USET SPF,
along with Tribal Nations and other regional and national
organizations, has consistently advocated for all federal programs and
dollars to be eligible for inclusion in self-governance compacts and
contracts.
Attempts to expand self-governance compacting and contracting
administratively have encountered barriers due to the limiting language
under current law, as well as the misperceptions of federal officials.
In 2013, the Self-Governance Tribal Federal Workgroup (SGTFW),
established within the HHS, completed a study exploring the feasibility
of expanding Tribal self-governance into HHS programs beyond those of
IHS and concluded that the expansion of self-governance to non-IHS
programs was feasible, but would require Congressional action. USET SPF
maintains that if true expansion of self-governance is only possible
through legislative action, Congress must prioritize this action. We
strongly support legislative proposals that would create a
demonstration project at HHS aimed at expanding ISDEAA authority to
more programs within the Department. In addition, a major priority for
Tribal Nations during the upcoming reauthorization of the Special
Diabetes Program for Indians (SDPI), along with increased funding and
permanency for the program, is ISDEAA authority. USET SPF looks forward
to supporting legislation aimed at fulfilling these priorities during
this Congress.
Improve Public Health Funding and Data Sharing
Many of the challenges and shortfalls plaguing the Indian Health
Care System are the result of sustained, chronic underinvestment in
prevention and public health measures paired with generations of
historical trauma and structural discrimination. As the United States's
public health infrastructure took shape and grew throughout the
twentieth century, Tribal Nations were routinely left out of resource
distribution. While Tribal Nations have always and continue to invest
in the health and wellbeing of our citizens, our efforts continue to be
hampered by lack of funding and inconsistently applied data sharing
authorities. In order to more effectively respond to the challenges in
our communities, including those posed by current and future public
health crises, Tribal Nations need increased resources as well as the
ability to efficiently and easily obtain necessary public health data.
In an already strained funding environment, there are often little
resources left for public health prevention and surveillance activities
in Tribal Nations. Although the IHS supports limited public health
activities at federally operated facilities, the primary responsibility
for the development and delivery of public health infrastructure and
services often lies with Tribal Nations, particularly in regions with
high concentrations of self-governance Tribal Nations. While many
Tribal Nations and IHS regions have worked to incorporate some public
health components in their governments, these entities often do not
operate at the same capacity as state programs, and certainly lack much
of the authority afforded to state entities. The Indian Health Care
Improvement Act (IHCIA) authorized the formation of Tribal Epidemiology
Centers (TECs), and since 1996, the TECs have been working to improve
the capacity of Tribal health departments to deal with public health
issues and priorities. TECs are charged with seven main functions,
including data collection, evaluation of systems, and the provision of
technical assistance to Tribal Nations. The USET TEC, which serves
Tribal Nations in the Nashville IHS Area, provides both aggregate and
Tribal Nation-specific public health and mortality data in addition to
its other functions. However, despite the critical nature of this
invaluable work and Congressional directives to share data, TECs
struggle with accessing public health data not only on the federal and
state levels, but the Tribal levels as well. Access to timely, accurate
data is vital to the delivery of healthcare services in Indian Country,
as it is difficult to direct resources appropriately without fully
understanding the challenges facing our people.
Congress has the obligation to correct these challenges within
Indian Country. In addition to providing full funding to the IHS,
Congress must meaningfully invest in public health capacity building in
Indian Country. Funding for expanding the Community Health Aide Program
(CHAP) to the lower 48 is one example of necessary investments in
public health and preventative care in Tribal Nations. To mitigate
challenges in data access, the federal government should compel
agencies like the Centers for Disease Control and Prevention (CDC) and
the Centers for Medicare and Medicaid Services (CMS) to issue specific
guidance to states and other public health entities directing them to
comply with legislative directives to share usable data with Tribal
Nations. USET SPF is appreciative of efforts within the Subcommittee to
conduct oversight in these matters.
Discussion Draft Recommendations
Clarification for Tribal Health Programs
While it appears that this bill is intended to apply to IHS-
operated health care facilities only, we are concerned that potential
unintended impacts to Tribal Nations operating facilities pursuant to
the Indian Self-Determination and Education Assistance Act (ISDEAA),
P.L. 93-638 have not been adequately examined. ISDEAA is among the most
successful federal Indian policies, as it recognizes our inherent
Tribal sovereignty and self-determination by ensuring we--and not the
federal government--are in the drivers-seat in addressing the needs of
our communities. USET SPF member Tribal Nations operate in the
Nashville Area of the Indian Health Service, which contains 36 IHS,
Tribal, and urban health care facilities, of which 26 are Tribally-
operated through contracts and compacts. Through exercising this self-
governance authority under ISDEAA, USET SPF Tribal Nations have greater
flexibility and control over federally funded programs to more
efficiently and effectively utilize funding to meet the unique
conditions within our Tribal communities. It is absolutely critical
that the effects of this legislation on Tribally-operated programs are
analyzed and consulted upon before it receives any further
consideration.
Unfunded Mandates
Several provisions place additional administrative requirements on
the IHS without providing additional resources for the agency to carry
these out. USET SPF is concerned that in addition to creating
compliance difficulties for the agency, these provisions will overtax
the agency's existing administrative resources to the point of
impacting other agency functions. It is unrealistic to expect that
these new requirements can be successfully implemented in the absence
of increased funding. As written, these new requirements will only
exacerbate existing difficulties faced by the agency.
Section-by-Section Comments
Below, USET SPF offers section-by-section comments and concerns.
Again, this bill should not move forward without additional, thorough
Tribal Consultation on a national basis.
Section 101. Incentives for Recruitment and Retention.
In order to address the ongoing challenges with the recruitment and
retention of IHS staff, the legislation would allow HHS to provide
housing vouchers or reimburse the costs for those relocating to an area
experiencing a high level of need for employment. Though this provision
provides the Secretary discretion to determine whether a location is
experiencing a high level of need, USET SPF suggests including language
for positions that are ``difficult to fill in the absence of an
incentive.'' This addition would allow IHS more flexibility when
determining when to offer relocation compensation.
USET SPF agrees that there is a need for recruitment and retention
programs. However, the establishment of these programs should not come
at the cost of health care services. USET SPF recommends that
additional appropriations be authorized for the proposed recruitment
and retention programs.
Additionally, it is unclear why the bill includes a sunset date on
the housing voucher program. It is unlikely that IHS staff housing
needs will be fully addressed in only a 3-year period. USET SPF
suggests that the sunset date be stricken.
Section 102. Medical Credentialing System.
This section would create a uniform, standardized, and central
credentialling system for the IHS to use in its hiring procedures. USET
SPF has deep concerns about the centralization of any Area Office
functions, including credentialing. Nashville Area Tribal Nations have
consistently advocated for Area Office presence and for services to be
administered at the Area level. Collectively, we have worked hard to
establish the strong relationship we have with our Area Office today.
Taking away functions from Area offices causes significant backlogs in
services, and disrupts an established and trusted relationship between
the Area Office and Tribal Nations. We believe credentialing should be
kept at the Area level, utilizing established best practices. In
addition, this provision serves as an example of the aforementioned
unfunded mandates included in this bill.
Section 104. Clarification Regarding Eligibility for Indian Health
Service Loan Repayment Program.
USET SPF encourages efforts that would expand the Indian Health
Service Loan Repayment Program to include degrees in business
administration, health administration, hospital administration, or
public health professions as eligible for awards. We recommend
including language that would expand these degrees as eligible under
the IHS Scholarship Program as well. Allowing for comprehensive
eligibility under these programs would increase the number of AI/AN
individuals seeking business and health administration degrees, as well
as increase the pool of qualified health professionals within Indian
Country. In addition, we have long supported legislation that would
confirm the nontaxable status of IHS student loan repayments in parity
with other federal loan repayment programs.
Section 105. Improvements in Hiring Practices.
This section makes several changes to the IHS's hiring authority
that aim to give the Agency more ability to quickly address staffing
shortages. First, it gives the IHS Direct-Hire Authority, which allows
the Agency to bypass certain federal hiring procedures in order to
appoint candidates directly to positions when there is a severe
shortage of candidates or a critical hiring need.
On Waivers of Indian Preference, USET SPF firmly believes that the
providers best suited to care for our communities are ones that come
from the communities themselves. At the same time, there is room for
improvements in hiring practices to ensure that positions are being
filled in a timely manner with qualified candidates. We appreciate the
inclusion of language to require Tribal requests to waive Indian
Preference in order for the Agency to do so. However, we note that IHS
included this policy change in its FY 2024 Budget Request in the
absence of Tribal consultation or a provision requiring Tribal Nation
approval. With this in mind, it is absolutely essential that this
provision receive thorough Tribal consultation. Tribal Nations must
guide its development and implementation to ensure that it accomplishes
its aims without negatively impacting the development of a culturally
competent workforce.
Section 106. Improved Authorities of Secretary to Improve
Accountability of Senior Executives and Employees of the Indian
Health Service.
While USET SPF understands the purposes of including language that
would expand the Secretary's authority to remove or demote IHS
employees based on performance or misconduct, we believe Tribal
governments must also be notified when IHS employees within their
Service Area become subject to a personnel action such as removal,
transfer or demotion. In addition, we ask that the Report to Congress
describing the 1-year period following the enactment of this provision
also be shared with Tribal Nations.
Section 107. Tribal Culture and History.
USET SPF has consistently supported additional training for all
federal employees on the nature and history of U.S.-Tribal Nation
relations, trust and treaty obligations, and respectful diplomacy with
Tribal Nations. With this in mind, we support the inclusion of Section
107. However, because each Tribal Nation is a unique sovereign entity,
language should be included that would require each IHS Area to design
these trainings through consultation with the Tribal Nations they serve
on a regional basis. This will allow the training to encompass regional
cultural commonalities, as opposed to attempting to ascribe cultural
similarities to Tribal Nations across the country.
Section 108. Staffing Demonstration Program.
This section would establish a demonstration project to provide
staffing resources to individual clinics or service units. While we
support efforts to increase staffing throughout the Indian Health
System, our concerns with this provision are similar to those with
Section 101. Financial resources are essential to the proper
implementation to this provision. In addition, it remains unclear how
the Agency would take just four years to make the program self-
sustaining--especially without increased appropriations. Finally, the
Agency appears to have outsize discretion in choosing sites for the
demonstration.
Section 111. Enhancing Quality of Care in the Indian Health Service.
This section contains many provisions aiming to enhance the quality
of care at IHS. While we appreciate Tribal consultation requirements
and assurances that parts of this provision are optional for Tribally-
operated facilities, we want to underscore the need to ensure that the
diversity of Tribal Nations and Indian Country is reflected in the
development of this provision. What may work for one Area and the
Tribal Nations it serves may not work for another. In addition, any
necessary resources should be extended to IHS in order to comply.
Section 112. Notification of Investigation Regarding Professional
Conduct; Submission of Records.
This section requires the IHS to notify relevant Medical Boards no
later than fourteen calendar days after starting an investigation into
the professional conduct of a licensee at an IHS facility. This
notification should also be extended to Tribal Nations served by that
particular facility.
Section 113. Fitness of Health Care Providers.
Similarly, the reporting to Medical Boards under this provision
must also be extended to Tribal Nations served.
Section 114. Standards to Improve Timeliness of Care.
This section requires IHS to establish standards that measure the
timeliness of health care services provided in in IHS facilities. It is
imperative that any timeliness of care standards are developed in
consultation with Tribal Nations and that this section confirms
unequivocally that the standards do not apply to Tribally-operated
facilities. In addition, we request that any data collected under the
provision be provided to Tribal Nations as well as the Secretary.
Section 203. Fiscal Accountability.
USET SPF has concerns with this section and its effect on base
funding. This section requires further technical evaluation and
explanation, including from IHS, in order to assess its true impact.
Sections 302-304. Reports by the Secretary of HHS, Comptroller General,
Inspector General.
USET SPF recommends including language that would require greater
collaboration and consultation with Tribal Nations. We feel the reports
laid out in this section should be conducted in collaboration with
Tribal Nations and provided to those Tribal Nations for consultation
prior to their release to Congress or the public.
Section 305. Transparency in CMS Surveys.
As above, USET SPF recommends adding language that would require
collaboration and consultation with Tribal Nations during the
formulation of these compliance surveys. We also believe the results of
these surveys should be provided to Tribal Nations prior to their
public release.
Conclusion
USET SPF acknowledges the efforts of the Committee and others
within Congress in seeking to address the long-standing challenges
within IHS. However, we believe that the discussion draft continues to
fail to recognize the deep disparities in funding faced by IHS and how
these disparities contribute to failures at the Area level. We maintain
that until Congress fully funds the IHS, the Indian Health System will
never be able to fully overcome its challenges and fulfill its trust
obligations. Finally, a number of provisions within the bill seem to be
responding to Area-specific concerns. While we stand with our brothers
and sisters who are experiencing these failures, we ask that the
Committee strongly consider the national (rather than regional)
implications of the bill, and work with Tribal Nations to ensure its
impact is positive in all IHS Areas. We thank the Committee for the
opportunity to provide comments on this bill and look forward to
further consultation The IHS Accountability Act, as well as an ongoing
dialogue to address the complex challenges of health care delivery in
Indian Country.
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